General Thoracic and Cardiovascular Surgery Cases最新文献

Background: Transcarotid transcatheter aortic valve replacement (TAVR) is a safe procedure with a low incidence of cerebral infarction and has recently become the first-choice alternative approach. This procedure requires temporary occlusion of the common carotid artery (CCA). CCA clamping during surgery may help reduce the risk of embolism caused by debris; however, the risk of hemodynamic stroke cannot be entirely ruled out. Therefore, intraoperative monitoring of cerebral ischemia is essential. Regional oxygen saturation (rSO₂) monitoring is commonly used, but can only measure local mixed venous oxygen saturation in the frontal lobes. During carotid endarterectomy (CEA), a combination of multiple monitoring methods for intraoperative cerebral ischemia is recommended. Similarly, we used somatosensory-evoked potentials (SEPs) in conjunction with rSO₂ monitoring.

Case presentation: A 92-year-old male patient with a history of dyspnea on exertion was diagnosed with severe aortic valve stenosis (AS) using transthoracic echocardiography (TTE). Contrast-enhanced computed tomography (CT) revealed a shaggy aorta extending from the aortic arch to the descending aorta. Preoperative magnetic resonance angiography (MRA) of the head showed slight narrowing of the anterior communicating artery. Considering the patient's age, frailty, and vascular pathology, we performed transcarotid TAVR while monitoring rSO₂ and SEPs for intraoperative cerebral ischemia. No significant decreases in rSO₂ values or SEPs amplitudes due to occlusion of the left CCA. The procedure was successful, with no postoperative stroke, and the patient had an uneventful recovery.

Conclusions: In transcarotid TAVR requiring CCA occlusion, monitoring cerebral ischemia with both rSO₂ and SEPs may help prevent perioperative hemodynamic cerebral infarction.

Background: Hemolytic anemia following transcatheter aortic valve implantation (TAVI) is an uncommon complication, particularly in patients with only mild paravalvular leak (PVL). Although reports of TAVI valve explantation are increasing, the procedure remains technically demanding and is associated with high morbidity and mortality. This case highlights the importance of early surgical consideration when hemolytic anemia occurs post-TAVI, despite only mild PVL.

Case presentation: An 83-year-old man with symptomatic severe aortic stenosis underwent transfemoral TAVI via a 26-mm SAPIEN 3 Ultra RESILIA® valve. Although classified as low surgical risk, TAVI was chosen on the basis of patient preference and age. The procedure was uneventful, with only mild PVL observed via transesophageal echocardiography. The patient was discharged on postoperative day 10. One month later, he presented with fatigue and laboratory findings indicating severe hemolytic anemia. Echocardiography revealed a PVL jet from the non-coronary to left coronary cusp commissure. Preoperative CT revealed bulky annular calcification, especially at the NCC-LCC commissure. Owing to worsening anemia and ongoing hemolysis, surgical explantation and aortic valve replacement were performed. Intraoperatively, a gap was found between the valve and the annulus at the calcified commissure. The TAVI valve was successfully explanted and replaced with a surgical bioprosthesis. Postoperative recovery was uneventful, and hemolysis resolved completely.

Conclusions: This case demonstrates that mild PVL after TAVI may still cause clinically significant hemolysis depending on anatomical features. Careful preprocedural assessment of annular calcification and commissural geometry is critical, even in low-risk patients. Surgical explantation should be considered early when hemolysis occurs, as delayed intervention may lead to increased morbidity. This case reinforces the need for individualized valve selection and close follow-up to address the adverse hemodynamic consequences of PVL promptly, regardless of its apparent severity.

Background: Cold agglutinin disease (CAD) is sometimes incidentally detected before cardiovascular surgery. Several methods to prevent complications associated with CAD after cardiac surgery have been reported, but there are no reports of the use of physician-modified TEVAR to date.

Case presentation: A 76-year-old man with an arch aortic saccular aneurysm was scheduled to undergo arch aortic replacement. However, cold agglutinin syndrome was incidentally detected before open heart surgery. The safety of cardiopulmonary surgery under hypothermia for patients with cold agglutinin disease is unknown, as intravascular hemolysis is a source of concern for patients sensitive to cold stimulation. Instead, we performed physician-modified thoracic endovascular aortic repair (3 fenestrations and 1 branch), as the aneurysm in this case was suitable for thoracic endovascular aortic repair (TEVAR). As a result, the patient recovered well without any complication.

Conclusions: The long-term prognosis of physician-modified thoracic endovascular aortic repair remains unclear, and its use is limited to high-risk patients who require open chest surgery. Also, the impact of cold agglutination on stent grafts in CAD patients has not been reported. Despite that situation, this case illustrated that physician-modified TEVAR can be safely performed without significant postoperative complications, such as coagulation-fibrinolytic abnormalities or embolic events. Further studies are needed to establish the indications for this procedure in CAD patients.

Background: The COR-KNOT device is widely used in minimally invasive cardiac surgery, and its efficacy in reducing operative time is well established. However, it has been associated with complications, such as valve leaflet perforation and prosthetic valve damage.

Case presentation: We report a rare case of aortic root injury caused by COR-KNOT usage. A 72-year-old man with severe aortic stenosis due to a bicuspid aortic valve and distorted aortic root anatomy underwent minimally invasive aortic valve replacement using the COR-KNOT. After aortotomy closure, vigorous bleeding from the aortic root was observed. Punctate injuries of the aortic root, corresponding to the COR-KNOT clip sites, were identified following re-aortic cross-clamping. The procedure was converted to median sternotomy, the aortic root injury was repaired with an autologous pericardial patch, and the bioprosthetic valve was re-implanted using hand-tied sutures. The patient recovered uneventfully.

Conclusions: This case highlights the importance of careful device selection and clip positioning in anatomically challenging cases to avoid life-threatening complications.

Background: Papillary fibroelastoma is a rare, benign cardiac tumor that typically originates from the cardiac valves, with papillary muscle involvement being extremely rare. However, optimal management of papillary fibroelastoma remains variable.

Case presentation: A 79-year-old female with multiple comorbidities, including Parkinson's syndrome, diabetes, and frailty, was referred to our hospital because an incidental left ventricular mass was detected during a preoperative evaluation for knee osteoarthritis. Echocardiography and computed tomography revealed a mobile, 17-mm mass in the left ventricle, possibly attached to the posterior papillary muscle. The morphological findings were suspicious for papillary fibroelastoma. The tumor was surgically resected from the papillary muscle using a three-dimensional thoracoscopy-assisted right limited-thoracotomy approach. Histopathological analysis confirmed the diagnosis of papillary fibroelastoma. Postoperatively, the patient was discharged without complications, and no recurrence was observed at the 1-year follow-up.

Conclusion: This case demonstrates the feasibility and efficacy of minimally invasive video-assisted right thoracotomy for the resection of a papillary fibroelastoma originating from the papillary muscle.

Background: The anomalous origin of the left circumflex coronary artery is rare and, when isolated, typically has minimal pathological significance. However, it can cause damage or compression of the coronary artery during aortic and mitral valve surgery.

Case presentation: The patient was a 34-year-old male diagnosed with severe aortic regurgitation due to a bicuspid aortic valve following infective endocarditis at the mitral valve. He was referred to our hospital owing to worsening heart failure. Preoperative evaluation revealed a mitral valve aneurysm and an anomalous left circumflex coronary artery originating from the right coronary artery and running posteriorly along the aortic valve annulus. During surgery, dissection of the anomalous left circumflex coronary artery was challenging. Mitral valve aneurysm repair and aortic valve replacement were performed. For the aortic valve replacement, a 23-mm St. Jude Medical Regent valve, one size smaller than optimal, was secured in the supra-annular position. Additionally, a coronary artery bypass graft was performed on the distal circumflex artery using a saphenous vein graft. The patient experienced no ischemic myocardial damage and was discharged in stable condition on postoperative day 14.

Conclusions: The anomalous origin of the left circumflex coronary artery should be recognized, and appropriate measures must be taken during valve surgery. Preemptive coronary artery bypass grafting is a reasonable option for patients undergoing aortic and mitral valve surgeries.

Background: Survival can be prolonged in patients with end-stage heart failure using left ventricular assist devices (LVADs); however, increased longevity raises the risk of developing noncardiac complications, including malignancies requiring surgery.

Case presentation: A 58-year-old man with an LVAD was referred for the diagnosis and treatment of an undiagnosed nodule in the right upper lobe, which was detected during a preoperative computed tomography (CT) scan, for heart transplantation assessment. CT revealed a 9-mm nodule in the right anterior segment (S³), and an 18F-fluorodeoxyglucose positron emission tomography showed significant uptake, suggestive of lung cancer. A robot-assisted thoracoscopic right S³ segmentectomy was performed. Intraoperative hemodynamic monitoring included an arterial line, a central venous catheter, a pulmonary arterial catheter, and transesophageal echocardiography. The procedure was completed successfully without complications. Pathological analysis confirmed adenocarcinoma, classified as pathological stage T1aN0M0 (Stage IA1). The patient subsequently underwent heart transplantation and LVAD removal on postoperative day 185.

Conclusions: A patient with lung cancer and an LVAD who was awaiting heart transplantation successfully underwent robot-assisted thoracoscopic right S³ segmentectomy, enabling him to subsequently undergo a heart transplant.

A 21-year-old female patient had undergone two open heart surgeries in childhood, including Konno ventriculoplasty with mechanical aortic valve replacement. She underwent a redo mechanical aortic valve replacement and patch enlargement of stenotic ascending aorta using a triplex prosthetic graft. Unfortunately, 1 month after surgery, the patient was readmitted to the hospital with a diagnosis of midline chest wound infection. A culture sample from the wound revealed Serratia marcescens, however, subsequent all culture tests were negative. Since then, there has been a continued serous discharge from the caudal side of the midline skin incision scar and chest tube removal scar in the chest. Despite the implementation of four open chest treatments, the issue of perigraft seroma persisted, and a diagnosis was ultimately made. During her subsequent admission, negative pressure wound therapy was employed, followed by daily sterilization and film dressing post-discharge. It is understood that a gradual decrease in drainage and complete resolution of the seroma occurred 21 months after surgery, without the removal of the implanted triplex patch.

Background: We report a computational fluid dynamics (CFD)-based analysis of an unsuccessful open fenestration for aortic dissection with mesenteric malperfusion.

Case presentation: A 75-year-old male was admitted for acute type B aortic dissection complicated by mesenteric malperfusion. He had a concomitant infrarenal abdominal aneurysm, prompting surgical infrarenal fenestration. Intraoperatively, the proximal intimal flap was resected near the renal arteries, and the aneurysm was replaced with a prosthetic graft. Despite the intervention, mesenteric malperfusion worsened, requiring additional endovascular aortic repair. CFD analysis revealed persistent false lumen flow and true lumen compression due to a large entry tear and residual proximal anastomotic stenosis.

Conclusion: CFD analysis suggests that a large entry tear and residual stenosis from insufficient fenestration may result in inadequate false lumen depressurization.

Background: Valvular injuries in chest trauma mostly affect the aortic and mitral valves, but traumatic tricuspid regurgitation (TR) remains rare. This report describes the successful repair of traumatic TR secondary to papillary muscle rupture complicated with right ventricular (RV) free wall injury and atrial septal perforation.

Case presentation: A 50-year-old male suffered blunt chest trauma from a tree fall, leading to multiple fractures, mediastinal hematoma, and hemoperitoneum caused by splenic bleeding. Given that heart failure worsened eventually, echocardiography was conducted on day 7, showing significant TR resulting from leaflet prolapse caused by papillary muscle rupture with concomitant 4.8 mm atrial septal perforation and focal RV free wall thinning. Nonetheless, the heart failure was responsive to medical treatment. The patient was then scheduled for surgery 1 month later. The atrial septal defect was closed via direct suture closure. The RV free wall injury presented with scarring and did not require repair. The tricuspid valve repair included suturing the ruptured medial papillary muscle to the RV wall, reconstructing the ruptured posterior leaflet chordae with prosthetic chordae, and securing an annuloplasty ring. Consequently, TR was completely controlled.

Conclusions: Traumatic tricuspid valve injuries are rare. The optimal timing of surgery for traumatic TR remains controversial. However, early diagnosis and intervention are recommended to prevent progressive RV dysfunction and improve the success of tricuspid valve repair.