A 49-year-old man was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention (PCI) for complete left anterior descending artery (LAD) occlusion. Two weeks later, transthoracic echocardiography revealed a mobile left ventricular thrombus. Due to its increasing size despite anticoagulation therapy, he was transferred to our department. Emergency surgery was performed using a totally endoscopic trans-atrial and trans-mitral approach through a right minimally invasive thoracotomy. The thrombus was completely removed under direct endoscopic visualization without the need for left ventricular incision. The postoperative course was uneventful, and no residual thrombus was observed. This minimally invasive approach is considered safe and effective for selected patients.

Minimally invasive cardiac surgery (MICS) for redo mitral valve surgery in the presence of severe atheroma and atherosclerotic diseased atherosclerotic and artheromic aorta presents significant challenges and increases the risk of postoperative cerebral infarction. At our institution, to mitigate the risk of postoperative cerebral complications, we employ a strategy combining antegrade and retrograde perfusion during MICS for patients with atherosclerotic and artheromic aorta. However, the mixing zone during cardiopulmonary bypass (CPB) with combined antegrade and retrograde perfusion has not been thoroughly evaluated. In this case, we performed a completely endoscopic MICS redo mitral valve plasty (MVP). CPB was established using cannulation of both the ascending aorta (Asc Ao) and the femoral artery (FA). The patient received planned systemic hyperkalemia without an aortic cross clamp. In addition, due to aortic insufficiency, circulatory arrest was also needed. The patient experienced an uneventful post-operative recovery without any cerebral complication. Furthermore, we evaluated the mixing zone during the combined antegrade and retrograde perfusion using an arteriovenous circulation model. Our findings suggest that when performing perfusion via the Asc Ao and FA, it is advisable to select Asc Ao cannulation size reduced by one size against FA cannulation size to optimize the procedure.

The surgical management of preoperative malperfusion poses considerable challenges, particularly in cases of acute type A aortic dissection (TAAD). Herein, we describe the case of a 78-year-old female patient presenting with TAAD complicated by malperfusion of the left lower extremity and an entry tear localized to the ascending aorta. During the initiation of cardiopulmonary bypass (CPB), a pronounced bilateral discrepancy in radial mean arterial blood pressure (mABP) was identified, alongside a significant reduction in cerebral tissue oxygenation index (TOI) and the oxyhemoglobin change rate (ΔHbO2). To mitigate the malperfusion, pulsatile flow (PF) was utilized during CPB. This report elucidates the meticulous application of PF during CPB in the management of this complex malperfusion scenario, culminating in a favorable postoperative outcome.

Objectives: This study aimed to assess whether continuous furosemide administration during cardiopulmonary bypass (CPB) in minimally invasive cardiac surgery (MICS) reduces the incidence of cardiac surgery-associated acute kidney injury (AKI). Methods: A total of 100 patients undergoing MICS with CPB were randomly assigned to receive either continuous furosemide infusion or no continuous furosemide during CPB. The primary endpoint was the incidence of AKI. Secondary endpoints included the cardiac surgery-associated neutrophil gelatinase-associated lipocalin (CSA-NGAL) score, urine output within 12 h postoperatively, postoperative furosemide dose requirements, red blood cell transfusion volume, PaO2/FiO2 ratio, duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and in-hospital mortality. Results: AKI occurred in 8 patients (16%) in the continuous furosemide group and in 6 patients (12%) in the non-continuous group (relative risk, 0.72; 95% CI, 0.23–2.23). Among the secondary endpoints, urine output within the first 3 h postoperatively and the PaO2/FiO2 ratio were significantly higher in the continuous furosemide group. However, subgroup analyses revealed no significant differences between the two groups. Conclusions: Continuous furosemide administration during CPB did not effectively reduce the incidence of AKI. However, it was associated with a significant increase in postoperative urine output and an improvement in the PaO2/FiO2 ratio.

The conventional median sternotomy approach in aortic and mitral valve surgery may increase injury risk in critically ill patients. Functional mitral regurgitation (MR) is frequently observed in patients undergoing aortic valve interventions. While aortic valve replacement (AVR) and transaortic

背景:人工心肺(cardiopulmonary bypass:CPB)における急性腎障害(acute kidney injury:AKI)は、予後を悪化させる主要な合併症であると報告されている。今回、CPBを用いた心臓血管術後のAKIに関して後方視的に検討した。

症例は79歳男性．重症大動脈弁狭窄症を指摘され手術加療の方針となった．術前の経胸壁超音波検査では，左室流出路狭窄や僧帽弁収縮期前方運動Systolic anterior motion (以下SAM) の指摘はなかった．手術は生体弁 (INSPIRIS RESILIA 23 mm，Edwards Lifesciences) をsupra annular positionで縫着．大動脈弁遮断解除までは特に問題なく進めることができたが，人工心肺からの離脱が困難となり，経食道超音波検査にて僧帽弁収縮期前方運動SAM，severe MR, 左室流出路狭窄 (LVOTO) が認められた．ボリューム負荷，カテコールアミン中止，β-Blocker投与などの内科的治療で対応するも持続性はなく血行動態は不安定で，second pumpにて僧帽弁に対して外科的処置を追加する方針となった．手術はAlfieri Stitch (edge to edge) を施行し，リークテストでリークなし．遮断解除後の経食道超音波検査にてSAMとLVOTOともに消失しMRはmildで制御できており，人工心肺からの離脱を開始した．離脱は容易に行うことができ，手術は終了となった．その後の血行動態は良好で，術後2週間後の経胸壁超音波検査でも問題なく術後20日目に退院となった．退院後もSAM再発やMRの悪化なく順調に経過している．

Chronic limb-threatening ischemia (CLTI) is associated with a short-term risk of limb loss. Multidisciplinary teams are often involved in CLTI treatment; however, in Asian countries, multidisciplinary teams that include podiatrists specializing in foot wounds and vascular surgeons who can perform distal bypass surgery are lacking. We investigated predictive factors for limb salvage and foot ulcer recurrence in patients with CLTI treated by a Japanese single-center intensive multidisciplinary team over 6 years. We retrospectively investigated 84 patients with CLTI and foot ulcers who had undergone revascularization and wound treatment between October 2013 and December 2019. Following postrevascularization treatment, including undertaking minor amputations, the healing rate was 77.8%, and the average wound healing time was 75 ± 68 days. To achieve adequate blood supply, 17.7% of patients were treated using a combination of endovascular revascularization and bypass surgeries. Thirty-three (44%) patients had wound recurrence and there was wound recurrence within 6 months in 58.9% of these patients. Multivariate logistic regression analysis showed that postrevascularization skin perfusion pressure was significantly associated with wound healing (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.033-1.243, P = .0078). Diabetes mellitus (OR 9.72, 95% CI 1.855-50.937, P = .0071), and heart disease (OR 3.51, 95% CI 1.052-11.693, P = .0411) were significantly associated with wound recurrence (P < .05). Treatment within a single-center intensive multidisciplinary team resulted in good patient outcomes. Our study indicates that the revascularization endpoint of CLTI treatment should be marked by attainment of adequate blood supply and wound healing. The timing of revascularization and debridement is of utmost importance for the successful treatment of CLTI wounds.

Open repair of thoracoabdominal aortic aneurysm (TAAA) in a patient with severe aorto-iliac occlusive disease is considered to cause an extremely high risk for spinal cord injury. A 71-year-old man who had previously undergone axillo-bifemoral bypass for aorto-iliac occlusive disease presented with persistent dilation of a TAAA. Using distal perfusion via partial extracorporeal circulation at mild hypothermia, we performed segmental sequential repair of Crawford type II TAAA. Various efforts were made to avoid spinal cord injury and ischemic visceral organ damage. Consequently, the patient completely recovered without any serious complications.

Primary cardiac tumours are rare, the majority of which are myxomas, cardiac myxoma, the most common primary heart tumour, is located mainly in the left atrium (75%), followed by the right atrium (20%). In rare cases, myxomas can be found in the ventricles, and have been reported at a rate of 2.5%

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION Most cardiac tumours arise secondary to metastatic neoplasms. Smooth muscle tumours of the heart are rare. Here, we present the case of a large benign leiomyoma that metastasised from the uterus to the heart. A woman in her 40s was admitted to our medical centre with a cough, shortness of breath and abdominal pain. She had a history of uterine leiomyoma and underwent exploratory laparotomy and hysterectomy 10 years ago. Histopathological examination at the time revealed that the uterus contained multiple benign leiomyomata; necrosis, atypia or increased mitotic activity. During her current admission, physical examination revealed a systolic murmur of grade 4/6; an abnormal ‘plop’ sound was also audible at the left sternal border, in the fourth intercostal space. Transthoracic echocardiography revealed a huge rodlike tumour located in the right ventricle (figure 1A) and extending into the right ventricular outflow tract. The abnormal sound was related to the movement of the tumour. We suspected that the patient’s cough was caused by the tumour as it was stuck in the right ventricle outflow. Enhanced CT scan results corroborated echocardiography findings as well as revealing multiple small bilateral pulmonary nodules (figure 1B–D). Emergency cardiac surgery was performed via median sternotomy. After the right ventricular outflow incision was made, a mobile white dense tumour, measuring 97 × 32 × 20 mm, was found (figure 2A,B). The tumour was attached to the posterior wall of the right ventricle by a narrow stalk. A small spherical white nodule was also noted to be attached to the chordae, towards the anterior leaflet of the tricuspid valve. The nodule measured 20 × 5 × 3 mm. After the surgery, the patient recovered well. She was discharged home 8 days after the operation. Histological examination of the resected tumour revealed that it was composed of spindlelike cells, and interstitial collagen, resembling benign leiomyoma. This suggested a uterine origin as the cardiac leiomyoma was similar to her previous uterine leiomyoma. Very low levels of atypia and mitoses were discovered. Margins of resection were microscopically negative for tumour cells. Immunohistochemical staining for α-smooth muscle actin, desmin, and progesterone and oestrogen receptors was positive. Staining for CD34 was negative. At followup after cardiac surgery, there is no cardiac recurrence and no evidence of metastatic

Chronic expanding pericardial hematoma is a very rare disease that occurs after open-heart surgery. We report successful surgical treatment of a rare case of chronic expanding pericardial hematoma that developed into a large mass and presented as pericardial tamponade without apparent cause. An 82-year-old woman with no history of cardiac surgery, chest trauma, or epicardial injury presented with a 3-year history of progressive exertional dyspnea. Surgical resection of the mass via midsternotomy was planned to release the cardiac symptoms and to confirm the diagnosis of chronic expanding pericardial hematoma.

症例は，中咽頭癌に対して7カ月前に化学放射線療法を施行された72歳，男性．3カ月前に脳梗塞を発症し，リハビリ療法中であった．1カ月前より腰痛にて歩行困難となり，化膿性脊椎炎と診断され抗生剤投与を受けていた．2週間前より呼吸苦が出現，高度の肺うっ血にて3日前より人工呼吸管理となった．大動脈弁位の疣贅および高度の大動脈弁閉鎖不全症が認められ，感染性心内膜炎の診断で緊急手術となった．胸骨正中切開すると，前縦隔心左側に経食道エコーのプローブが見られ咽頭破裂と診断された．縦隔内を十分に洗浄し，生体弁を用いた大動脈弁置換術を行った後，開腹し大網を採取した．ついで頸部手術に移り，梨状窩の穿孔部を直接閉鎖，前縦隔を通した大網で咽頭修復部位を被覆し，胸骨を一期的に閉鎖した．術後経過は比較的順調で，術後32日目に一般病棟へ転室した．術中経食道エコープローブによる，稀できわめて重篤な咽頭破裂の合併症を経験し，救命したので報告する．

The midterm outcomes and aortic remodeling after thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) were evaluated. Forty-seven patients (mean age 66 ± 12 years) who underwent TEVAR for uncomplicated TBAD with double-barrel type from January 2012 to December 2017 were retrospectively analyzed. The indication for TEVAR for entry closure was a maximum aortic diameter > 40 mm with a patent false lumen. Twenty-six patients (55.3%) had TEVAR in chronic phase, over 6 months after the onset of aortic dissection. There was no hospital death or serious complication. During follow-up (mean 35 ± 16 months), overall 3-year survival was 95.6 ± 3.1%. A significant trend was observed with a higher rate of shrinkage of overall aortic diameter, expansion of the true lumen, and shrinkage of the false lumen more proximally from the stent graft-covered site. Rate of aortic shrinkage in chronic with aortic diameter more than 50 mm was lower compared with the other (proximal: 33.3% vs. 80–100%, distal 0–16.7% vs. 50–52.9%). Rate of aortic dilation distally to the stent graft-covered site was 28% in chronic compared with 5% in non-chronic. Adverse events were mainly due to distal aortic dilation, and 3-year freedom from all adverse events was 79.8 ± 6.5%. Favorable aortic remodeling of the proximal stent graft-covered site could be expected even in the chronic phase if preoperative aortic dilation over 50 mm is unaccompanied. Careful follow-up focusing on dilation of the distal aortic segment is mandatory especially in patients who underwent TEVAR in chronic phase.

Objective: To evaluate the long-term outcomes of heart valve replacement with mechanical prosthesis (MP) versus bioprosthesis (BP) in patients on dialysis. Methods: A retrospective review was performed at 7 hospitals. Patients on dialysis who underwent valve replacement were included. Survival, reoperation, bleeding, and embolic events were compared across the MP and BP groups. Results: Between April 2000 and April 2016, 312 patients on dialysis were enrolled in our study (MP: 94 patients [30.1%], BP: 218 patients [69.9%]) Mean follow-up was 3.4 +/- 3.6 years. Five-year and 10-year survival rates were similar in both groups (MP: 57.4 +/- 5.5% at 5 years and 46.3 +/- 6.4% at 10 years, BP: 50.2 +/- 4.1% at 5 years and 38.8 +/- 4.5% at 10 years, P = .305). Multivariate Cox hazard analysis demonstrated that diabetic nephropathy (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.31-2.73, P < .001), New York Heart Association functional classification >= III (HR, 2.16; 95% CI, 1.37-3.35, P = .001), and mitral valve replacement (HR, 2.36; 95% CI, 1.58-3.49, P < .001) were significant risk factors for late death. Valve selection was not a significant risk factor. Freedom from valve-related embolic event at 5 years was significantly lower in the MP group (MP: 88.3 +/- 4.3% at 5 years, BP: 97.2 +/- 1.6% at 5 years, P = .007). Freedom from valve-related reoperation or hemorrhagic events was similar across both groups. Conclusions: Valve selection was not associated with late survival outcomes in patients on dialysis. However, BP may have an advantage in preventing embolic events without increasing the incidence of valve-related reoperation when compared with MP.