Azumi Hamasaki

A modified surgical approach for giant left coronary arterial aneurysm

An 80-year-old female with a persistent cough was found on volumerendered tomorgraphy (CT) to have a 6.5× 5.7-cm coronary artery aneurysm compressing the posterior portion of the pulmonary artery (PA) (Fig. 1). Two smaller “daughter aneurysms” 1.5 and 1.4 cm were located on the anterior aspect of the PA (Fig. 1). In addition, a bronchial artery aneurysmwas also noted (Fig. 1). There were no coronary artery occlusions or fistulous communications between the aneurysm and any cardiac chamber seen on a coronary angiogram. At the time of surgery, a mediansternotomy was performed and cardiopulmonary bypass (CPB) was established with ascending aortic and bicaval cannulation. A 6-cm calcifiedmass was noted superior and posterior to the heart between the ascending aorta and PA (Fig. 2). Following cardioplegic arrest with antegrade/retrograde blood cardioplegia, a feeding artery arising from the proximal right coronary artery was ligated at its origin. Inadequate exposure of the proximal left main coronary (LMC) artery and the aneurysm necessitated transection of both the ascending aorta and the main PA (Fig. 3). A feeding artery arising from the LMC artery was ligated at its origin. The aneurysmal

Spontaneous rupture of a caseous calcification of the mitral annulus in a hemodialysis patient

We report a 56‐year‐old hemodialysis patient with a spontaneously ruptured caseous calcification of the mitral annulus resulting in multiple cerebral emboli. The mass was resected without replacing the mitral valve. The patient has remained symptom‐free 3.5 years following surgery.

Left ventricular lipoma with pseudoaneurysm-like appearance.

We describe an extremely rare cardiac lipoma, with electrocardiographic changes in ST segments and T waves, suggesting ischemic heart disease. The abnormal electrocardiogram was identified during a routine physical examination of an asymptomatic 57-year-old man. Coronary angiography showed no stenotic or occlusive lesions in the coronary arteries except that the left anterior descending artery followed a winding course in the apical region. Left ventriculography revealed a pseudoaneurysm-like mass around the apical portion. Computed tomography and magnetic resonance imaging revealed a cardiac lipoma that communicated with the left ventricle and resembled a pseudoaneurysm. After complete resection of the lipoma and left ventricle patch plasty, the postoperative course was uneventful. Histologically, the tumor was an intramyocardiac lipoma with no evidence of malignancy. To our knowledge, we are the first to describe an intramyocardiac lipoma resembling a left ventricle pseudoaneurysm.

One-stage hybrid surgery for Kommerell diverticulum and aortic valve stenosis

Kommerell diverticulum (KD) may be repaired on or off bypass with a single or staged procedure. KD may also be accompanied by coronary or valvular diseasewhich require concomitant repair. In such cases, a single-stage approach, such as that used for an ascending aortic dissection with distal extension may be required. This is preferable to an endovascular stent graft repair which may result in a proximal type 1 endoleak. We report the images of a single-stage repair of a patient with KD and aortic stenosis using a total arch replacement with a stent graft in the descending aorta to occlude the KD and a concomitant aortic valve replacement. A 65-year-old female who was referred for repair of a 4.2-cm abdominal aortic aneurysm (AAA) was found on a preoperative computed tomography (CT) angiogram to have a 6.0 cm KD with an aberrant right subclavian artery (ARSA) arising from the KD and passing posterior to the trachea and esophagus (Figures 1 and 2). An echocardiogram revealed a calcified aortic valve with a peak pressure gradient of 35mmHg and an aortic valve area of 0.65 cm. At the time of surgery, the right axillary artery was exposed and an end-side anastomosis was performed with a 9-mm prosthetic J graft (Japan Lifeline, Tokyo, Japan). Following a mediansternotomy, cardiopulmonary bypass (CPB) was instituted with ascending aortic and bicaval cannulation. The aorta was crossclamped and the heart arrested with antegrade/retrograde cold blood cardioplegia for 104 minutes. The aortic valve was excised and replaced with a #21-mm Trifecta

Proximal first: a beneficial strategy for no-touch saphenous vein graft

In the mid-1990s, a novel saphenous vein harvesting technique, in which the vein is harvested with its surrounding tissue without manual distention, was introduced. This no-touch technique provides an excellent long-term patency; however, graft twisting and kinking should be given attention. To fully bring out the benefit of the no-touch method while reducing the risk of twisting and kinking, we have modified the anastomosis strategy. Our simple modified strategy involved a proximal anastomosis prior to the distal anastomosis. This strategy was successfully used in 16 patients.

Simple and safe removal modification of the HEARTSTRING device

HEARTSTRING is a useful proximal anastomosis assist device, but it has a drawback in that the removal process is irreversible. If thread cutting occurs during the tying process, repair without side clamping is difficult. We developed a simple modified technique for the safe removal of the HEARTSTRING device.

Endovascular Repair of an Abdominal Aortic Aneurysm with Iliac Vein Compression Syndrome

An 84-year-old man with chronic obstructive pulmonary disease (COPD) was referred to our institution for further treatment of severe swelling of the left lower extremity. The left iliac vein was compressed by the abdominal aortic aneurysm and a right common iliac arterial aneurysm measuring 62 mm and 45 mm in diameter and was partially thrombosed. Multiple pulmonary artery embolisms were also noted. Endovascular repair of the abdominal aortic aneurysm and the right common iliac arterial aneurysm was performed because of his respiratory dysfunction. The left leg edema gradually resolved after endovascular treatment. Six months after the treatment, computed tomography (CT) demonstrated resolution of the venous thrombus of the left lower extremity. Although open surgery is reliable treatment for iliac compression syndrome, endovascular treatment might be a feasible and an adequate therapeutic option for patients who have severe comorbidities, complications, or high frailties.

Novel Surgical Technique for Coronary Fistulas With Proximal Origin

Postoperative residual shunting is a significant concern in patients with coronary arteriovenous fistulas, especially in fistulas originating from the proximal left coronary artery, because of the limited surgical field. We report a case of fistulas originating from the proximal coronary artery in a 63-year-old woman in whom the ascending aorta and pulmonary artery were transected to obtain good surgical exposure. After complete transection of both great arteries, fistulas arising from the left main trunk were ligated externally, and their intracardiac openings were closed internally. Postoperative examination revealed no residual shunt flow.

Takotsubo Cardiomyopathy after Hybrid Repair of Thoracic andThoracoabdominal Aortic Aneurysm

Context: Takotsubo cardiomyopathy is characterized by transient and acute left ventricular dysfunction with apical dyskinesia in the absence of coronary artery disease. The pathophysiology of this rare disease is considered to be associated with physical and psychological stress. Recently published case reports have described the association between Takotsubo syndrome and various surgical procedures as the causative stress factors. However, Takotsubo cardiomyopathy is extremely rare in patients who have undergone cardiovascular surgery. Case report: Here, we report a rare case of Takotsubo cardiomyopathy developing after thoracic endovascular aortic repair for chronic dissecting aortic aneurysm. Conclusion: This patient developed Takotsubo cardiomyopathy 14 days after thoracic endovascular aortic repair, potentially because of the prolonged perioperative physical and psychological stress induced by multi-stage surgery. To our knowledge, this is the first report of Takotsubo cardiomyopathy after thoracic endovascular aortic repair. Through this report, we emphasize the importance of considering the possibility of Takotsubo cardiomyopathy in patients presenting symptoms of cardiogenic shock and unexplained hemodynamic deterioration, despite having undergone relatively less-invasive cardiovascular surgery. Early diagnosis is required to initiate appropriate treatment and to minimize the chance of complications.

Surgical repair of a celiac artery aneurysm using a sutureless proximal anastomosis device

Some celiac artery aneurysms are not suitable for endovascular therapy. We describe the case of a 63-year-old man with a celiac trunk aneurysm extending to the hepatosplenic bifurcation. The aneurysm was resected and oversewn at the origin from the abdominal aorta. A saphenous vein bypass from the supraceliac aorta to the celiac artery bifurcation was performed using a sutureless anastomotic device (PAS-Port system; Cardica, Redwood City, Calif) to create the proximal anastomosis, eliminating the need for aortic clamping. This system is thought to make direct proximal aortic anastomosis safe and easy in patients requiring surgical reconstruction of celiac artery aneurysms.