Yoshiharu Nishimura

Lower mid-line skin incision and minimal sternotomy—a more cosmetic challenge for pediatric cardiac surgery

We performed ten operations in children using a lower mid-line incision and limited minimal sternotomy. The skin incision is made from the level of nipples to the lower end of the xiphoid process, and only the body of the sternum is cut vertically. There was neither operative mortality nor complications. The upper limit of the scar was, at the most, 1 cm beyond the level of the nipples, and was difficult to observe in typical open-necked shirts. We believe our method is suitable in fulfilling the cosmetic needs for eligible children.

The solitary cutaneous metastasis of asymptomatic colon cancer to an operative scar

Although umbilical or cutaneous metastases from asymptomatic internal malignancies are occasionally documented, the literature contains no report of a solitary cutaneous metastasis to an old operative scar from an asymptomatic internal malignancy. A rare case of colonic cancer presenting as a solitary subcutaneous metastasis to a lower abdominal scar resulting from an open prostatectomy is described in this communication. It was impossible to distinguish this subcutaneous metastasis from a pyogenic granuloma caused by residual sutures without histological evidence. Thus, a granuloma that persists despite repeated treatment may be a possible sign of asymptomatic internal malignancy.

The protective effect of a leucocyte removal filter on the lung in open-heart surgery for ventricular septal defect

We elucidated the protective effect of a leucocyte removal filter on cardiopulmonary bypass (CPB)-induced lung dysfunction during open-heart surgery for ventricular septal defect (VSD). Forty-six VSD patients were divided into two groups: (a) a control group of 22 patients in whom the banked blood was used to prime the CPB circuit, and (b) a leucocyte removal group of 24 patients in whom a leucocyte removal filter was used for priming and every supplement of banked blood during and after the operation. The respiratory index immediately after the CPB was significantly lower in the leucocyte removal group than in the control group (2.23 ± 0.22 vs 3.90 ± 0.68; p < 0.05). The duration of stay in the intensive care unit was significantly shorter in the leucocyte removal group (3.0 ± 0.4 vs 4.1 ± 0.4 days; p < 0.05). These data suggest that the use of a leucocyte removal filter for blood added to the CPB prime or administered after CPB may have protective effects on lung function after open heart surgery for VSD patients.

Vacuum-Assisted Closure for Mediastinitis after Pediatric Cardiac Surgery

Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.

Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair

PURPOSE We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation). RESULTS Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all). CONCLUSION Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.

Endovascular Stenting and Stent-graft Repair of a Hemorrhagic Superior Mesenteric Artery Pseudoaneurysm and Dissection Associated with Pancreaticoduodenectomy

This report presents a 73-year-old woman with intraperitoneal bleeding from a superior mesenteric artery (SMA) pseudoaneurysm and dissection after pancreaticoduodenectomy (PD). A self-expanding bare metal stent was placed in the distal SMA across the area of dissection, and a stent-graft was subsequently placed across the pseudoaneurysm emerging from the proximal site by overlapping the bare stent, resulting in complete exclusion of the pseudoaneurysm and control of the dissection. Bleeding was controlled after the endovascular procedure. The combination of endovascular stenting and stent-graft repair is feasible and useful in comorbid cases of SMA pseudoaneurysm and dissection.

Patch Repair of a Giant Left Ventricular Pseudoaneurysm After Mitral Valve Replacement

Left ventricular pseudoaneurysm (LVP) is a rare cardiac disorder. We describe the repair of a large LVP that was identified in a 73-year-old woman 10 months after she underwent mitral valve replacement for infective endocarditis at another hospital 10 months previously. Follow-up echocardiography showed an enlarged large mass beside the left ventricle, and computed tomography revealed a LVP and an orifice just beside the mitral annulus. We removed the implanted valve and closed the large orifice (35×4 mm) using a Xenomedica (Baxter Healthcare Corp, Horw, Switzerland) patch. Computed tomography 3 months later revealed a thrombosed LVP.

Comparison of the waveforms of transit-time flowmetry and intraoperative fluorescence imaging for assessing coronary artery bypass graft patency.

PurposeAn intraoperative fluorescence imaging (IFI) system, which can provide visual images, could be the common method for assessing graft patency intraoperatively. We conducted a prospective comparison of the diagnostic accuracy of both the fast Fourier transformation (FFT) analysis of transit-time flowmetry (TTFM) waveform and the IFI system to determine graft failure.MethodsThe study included 10 saphenous vein grafts (SVGs), all of which were aortocoronary grafts. Each patient underwent isolated coronary artery bypass grafting (CABG), including conventional CABG or off-pump CABG, and then underwent X-ray angiography after CABG. When intraoperative hemodynamics had stabilized, the grafts were evaluated with both the IFI system and TTFM. Based on the obtained flow profile of TTFM, certain variables were calculated. The waveforms of TTFM were analyzed with the FFT series. Harmonic distortion (HD) was calculated from the amplitudes, and the fundamental frequency was thus determined using the FFT series.ResultsThe IFI system demonstrated a satisfactory flow of all grafts. X-ray angiography demonstrated that one SVG was 75% stenosed, and the others were patent. The mean graft flow (MGF) and the pulsatility index (PI) of the patent SVGs were not significantly different from those of the stenosed SVG. The HD of the patent SVGs was significantly different from that of the stenosed SVG.ConclusionThe HD of the TTFM waveform can provide better diagnostic accuracy for detecting clinically significant grafts than MGF and PI of TTFM and the IFI system.

Abrupt rupture of an aortic arch aneurysm into the pulmonary artery

We report an extremely rare case of pulmonary artery dissection caused by an abrupt rupture of an aortic arch aneurysm into the pulmonary artery. An asymptomatic 80-year-old man was admitted to our hospital for elective surgical repair of aortic arch aneurysm. After admission, sudden onset of hoarseness and dyspnea developed. Echocardiography demonstrated an intimal flap in the pulmonary artery and abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, the pulmonary artery dissection involved the main pulmonary artery and both major branches. Total arch replacement and pulmonary artery reconstruction were successfully performed.

Successful in Situ Treatment of Infected Aortic Arch Prosthesis by Omental Wrapping

A 67-year-old man who underwent total aortic arch graft replacement with coronary artery bypass grafting developed postoperative Serratia mediastinitis. Re-operative debridement and irrigation were carried out. An infected aortic arch prosthesis was successfully treated by in situ disinfection followed by complete omental wrapping.