Purpose: In totally endoscopic off-pump left atrial appendage (LAA) closure and surgical ablation, securing the operative field is sometimes difficult in some patients because of a narrow working space caused by an elevated diaphragm or ventricles. In this study, we aimed to investigate the effectiveness of a method that facilitates securing the operative field using an artificial pneumothorax. Methods: We analyzed 71 consecutive patients who underwent totally endoscopic offpump LAA closure and bilateral pulmonary vein isolation. The factors contributing to the reduction in operative time were examined. The patients were divided into the following 2 groups according to whether or not an artificial pneumothorax was used: Group C comprised 24 patients without an artificial pneumothorax and Group A comprised 47 patients with an artificial pneumothorax. Results: There were no hospital deaths or major complications. The operative time was significantly shorter in Group A (108 +/- 26 minutes) than in Group C (198 +/- 77 minutes) (p <0.0001). Conclusions: In totally endoscopic off-pump LAA closure and surgical ablation, an artificial pneumothorax may be useful in reducing the operative time.

BACKGROUND: This study aimed to investigate the effects of surgical methods on pain duration and oral analgesic administration in patients who underwent cardiac surgery using various minimally invasive methods. METHODS: We included 90 patients who underwent an anterior incision with costal cartilage transection, lateral incision without costal cartilage transection, or total endoscopic cardiac surgery using a lateral incision and no retractor. Oral analgesics were postoperatively administered upon patient request. All the patients were instructed to rate their pain during the daytime 3 and 7 days postoperatively. RESULTS: Between-group differences included surgical method, wound size, operation/cardiopulmonary bypass time/cardiac arrest time, and intraoperative fentanyl dose. No differences were found in sex, age, diabetes status, paravertebral block use, or blood loss. The number of postoperative days, postoperative analgesic use, and pain 3 days postoperatively demonstrated no difference. Pain ratings were most severe for the costal cartilage resection group and least severe for the total endoscopic cardiac surgery group 7 days postoperatively. Similarly, patients who underwent costal cartilage research exhibited the highest rate of analgesic use for 30 days postoperatively, whereas patients who underwent total endoscopic cardiac surgery demonstrated the lowest. CONCLUSIONS: We revealed significant between-group differences in pain prevalence and postoperative oral analgesic administration in patients who underwent cardiac surgery relative to the minimally invasive surgical method used. ( Cite this article as: Sato S, Obata Y, Azami T, Fujimoto M, Inoue K, Okada K. Association between postoperative pain and analgesic use in minimally invasive cardiac surgery. J Cardiovasc Surg 2024 Oct 09. DOI: 10.23736/S0021-9509.24.13075-3)

Pulmonary artery catheter (PAC) is an important clinical tool that is used in the care of perioperative cardiac patients and unstable patients in the intensive care unit. Entrapment of the PAC by an intracardiac surgical suture is a rare complication. In open-heart surgery, the catheter may be caught by a suture placed through the right atrial wall because the catheter tends to lie against the anterior wall of the right atrium (RA).[1] In this letter, we describe the entrapment of the PAC to the interatrial septum by a left atrial suture, which was diagnosed using 2D- and 3D-transesophageal echocardiography (TEE). A 77-year-old male patient with a history of mitral valve regurgitation, atrium fibrillation, and shortness of breath presented for mitral valve replacement. In the operating room, a PAC was inserted through the right internal jugular vein without complication. The patient's intraoperative course was uneventful. He was transferred to the intensive care unit in a stable condition and was extubated on postoperative day 1. PAC removal was also attempted but immediately aborted due to resistance with attempted withdrawal. The chest radiograph showed an unnatural curvature of the PAC in the RA (Figure 1, black arrow in the left panel). PAC entrapment by a suture used to close the venous cannulation site for cardiopulmonary bypass (CPB) was suspected and the decision was made to remove the PAC surgically. Upon re-operation, the surgeon removed the suture that had been used to close the venous cannulation site, but the PAC remained entrapped. After careful intraoperative TEE evaluation, an unusual protrusion of the interatrial septum was seen in both 2D and 3D images (Figure 1, white arrow in right panel). This protrusion was thought to be caused by the suture that had been used to close the left atriotomy during the mitral valve operation. Due to these intraoperative TEE findings, the decision was made to open the atrium and remove the suture. Following this, the PAC, which had been penetrated by the suture, was successfully removed. The patient was extubated in the operating theater and his clinical course after this procedure was uneventful.Figure 1: Chest X-ray and TEE image of the pulmonary artery catheterPAC entrapment is a rare cause of PAC-associated complications with a reported incidence of 0.065%.[1] The possible causes of PAC entrapment include catheter knotting[2] and entrapment by suture.[34] Most often, suture entrapment of the PAC is due to the right atrial suture. In this case, however, PAC entrapment was caused by the left atrial suture that had extended into the interatrial septum. Intraoperative TEE was used to successfully identify this uncommon site of PAC entrapment and to guide surgical management. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Radiofrequency catheter ablation (RFCA) is a standard treatment for atrial fibrillation (AF). However, RFCA is associated with perioperative problems, such as systemic embolization, and asymptomatic brain infarction is frequently detected by magnetic resonance imaging immediately after RFCA for AF.1,2 Most embolic adverse events associated with RFCA are presumably caused by microbubbles or thrombus formation.3 A previous in vivo study suggested that endothelial hyperthermic injury by RFCA induces thrombus formation.

We present a safe approach of minimally invasive cardiac surgery (MICS) through thoracotomy using continuous retrograde cardioplegia through anterior thoracotomy. Continuous retrograde cardioplegia allows excellent continuous homogenous cooling of the heart during the ischemic period. Anterior thoracotomy facilitates cannulation of ascending aorta, and allows our all manipulations using the fingertips without the aid of a knot pusher or long-shafted surgical instruments.

Purpose: To discuss minimally invasive cardiac surgery aortic valve replacement ( MICS-AVR) approach via anterior thoracotomy using continuous retrograde cardioplegia. Continuous retrograde cardioplegia facilitates excellent continuous homogeneous cooling of the heart during cardiac arrest. Methods: We performed AVR using the proposed method in nine patients between June 2018 and September 2019. The median age of the patients was 73 (range: 43-84) years. The pleural space was entered via anterior thoracotomy. After opening of the right atrium, a retrograde cardioplegic cannula was inserted into the coronary sinus with a purse-string suture. Continuous cold blood retrograde cardioplegia was initiated at 700 mL/h. Results: Extubation in the operating room was performed in five (56%) patients. No new decreased function of the left and right ventricles was observed in intraoperative transesophageal echography or transthoracic echocardiogram. Conclusion: MICA-AVR through continuous retrograde cardioplegia is a safe technique.

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4-6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

症例は46歳男性．リウマチ性疾患・梅毒の既往歴はない．Marfan症候群の診断基準には該当しない．2008年7月頃より労作性呼吸困難が出現した．心エコーにおいて大動脈弁輪径：28 mm，ST-junction径：45 mm，上行大動脈径：50 mmであり，大動脈弁中央よりsevereのARを認めていた．以上の結果から大動脈弁輪拡張症による大動脈弁閉鎖不全症と診断され，手術目的にて当科紹介となった．大動脈弁は無冠尖と右冠尖が癒合した明瞭なrapheを伴う二尖弁であった．SJM社製27 mm Aortic Valved Graftを用いてModified Bentall手術を施行した．経過は良好であり，現在NYHA分類class Iへ改善し，経過している．

We report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 74-year-old man with no history of cardiac disease was admitted to our hospital for persistent pyrexia. The blood culture was negative. Echocardiography showed vegetations attached to the tricuspid valve with mild tricuspid regurgitation. Intravenous antibiotics therapy was unable to control the infection. So we performed tricuspid valve repair and annuloplasty using an artificial ring. The postoperative course was uneventful. After prophylactic antibiotic administration for 15 weeks, he was afebrile for 1 week without any medication. Thereafter he was discharged and has been free from any complication for over 16 months.

症例は62歳男性．56歳時に水腎症を発症し，CTガイド下針生検にて特発性後腹膜線維症と診断された．2003年7月からステロイド剤の内服を開始するとともに，水腎症は軽快し，2004年7月にステロイド剤の内服を中止した．その後も経過観察されていたが，2009年4月頃より左下肢腫脹を認め，CT，MRI，Gaシンチ検査と血液検査（血清IgG4高値），臨床経過により再燃した特発性後腹膜線維症に起因する左総腸骨静脈の閉塞と診断された．ステロイド療法と抗凝固療法にて左下肢腫脹は軽快した．現在慎重にステロイド剤を漸減しているが，再燃は認めていない．

BACKGROUND End-tidal P(CO(2)) (Pe'(CO(2))) is routinely used in the clinical assessment of the adequacy of ventilation because it provides an estimate of Pa(CO(2)). How well Pe'(CO(2)) reflects Pa(CO(2)) depends on the gradient between them, expressed as ΔPa-e'(CO(2)). The major determinant of ΔPa-e'(CO(2)) is alveolar dead space (Vd(alv)). The fraction of inspired O(2) (Fi(O(2))) is not thought to substantially affect ΔPa-e'(CO(2)) in anaesthetized patients. We hypothesized that a high Fi(O(2)) may indeed increase ΔPa-e'(CO(2)) by preferentially vasodilating well-perfused alveoli, resulting in the redistribution of blood flow to these alveoli from poorly perfused alveoli and an increase in Vd(alv). We therefore investigated the effects of changes in Fi(O(2)) on ΔPa-e'(CO(2)) and Vd(alv). METHODS With Institutional Review Board approval and informed consent, we studied 20 ASA I-II supine patients undergoing elective lower abdominal surgery under combined general and epidural anaesthesia. At constant levels of ventilation, Fi(O(2)) levels of 0.21, 0.33, 0.5, 0.75, and 0.97 were applied in a random order and ΔPa-e'(CO(2)) and Vd(alv) were calculated. RESULTS The ΔPa-e'(CO(2)) values were, in order of ascending Fi(O(2)), {mean [standard error of the mean (SEM)]} 0.13 (0.04), 0.28 (0.08), 0.29 (0.09), 0.44 (0.11), and 0.53 (0.09) kPa. The corresponding values of Vd(alv) were 25.5, 33.8, 35.8, 48.9, and 47.4 ml. Each successive hyperoxic level showed a significant increase in ΔPa-e'(CO(2)) except between the 0.33-0.5 and 0.75-0.97 Fi(O(2)) levels. CONCLUSIONS These data demonstrate that ΔPa-e'(CO(2)), in anaesthetized patients depends on Fi(O(2)).

A Case of Cystic Adventitial Disease of the Popliteal Artery and Study of 116 Cases Reported in Japan Hideki Takahashi, Naritomo Nishioka and Takashi Azami(Department of Cardiovascular Surgery, Yodogawa Christian Hospital, Osaka, Japan) We report a rare case of cystic adventitial disease of the popliteal artery causing intermittent claudication. About 2 months previously, a 21-year-old man had sudden intermittent claudication in the left leg. The left-sided ankle brachial pressure index(ABI)at rest was 0.66. Computed tomography revealed that the arterial occlusion was segmentally caused by cystic lesions. A cystic adventitial lesion of the popliteal artery, measuring 9 cm in diameter, was surgically removed and reconstruction was performed with a saphenous vein graft. Postoperatively the left ABI improved to 1.01, and his symptoms disappeared. The histopathological diagnosis was cystic adventitial disease and the cysts were in the adventitia. The postoperative course was uneventful and he has been without recurrence for 14 months. Jpn. J. Cardiovasc. Surg. 39 : 220-225(2010)

We report a case of penetrating atherosclerotic causing cardiac tamponade and subadventitial hematoma. A 72-year-old man was transferred with sudden onset of chest pain and a subsequent collapse. A computed tomography scan showed a pericardial effusion and a low density shadow around the ascending aorta. An emergency operation was conducted with a diagnosis of intramural hematoma complicating cardiac tamponade.The patient underwent replacement of the ascending aorta. The specimen of the ascending aorta showed severe atherosclerosis and no intramural hematoma. Histological evaluation revealed a hemorrhage which connected a small intimal ulcer to the subadventitial hematoma. We think this case suggest the entry oriented etiology of intramural hematoma not rupture of a vasa vasorum.

症例は68歳,女性.嗄声を主訴に近医耳鼻咽喉科を受診し,精査により最大短径60mmの遠位弓部大動脈瘤を指摘された.術前検査で右中大脳動脈閉塞による安静時の脳血流低下および脳血流予備能の低下が認められたため,胸部大動脈瘤手術に先立って右浅側頭動脈-中大脳動脈吻合術を行った.脳外科手術後18日目の脳血流シンチにて脳血流の改善を確認したのち,22日目に全弓部大動脈人工血管置換術を施行した.術直後から24ヵ月後の現在まで神経学的合併症はなく良好に経過している.本症例では浅側頭動脈-中大脳動脈吻合術を先行させ,二期的に胸部大動脈瘤手術を行うことで胸部大動脈瘤の周術期の虚血性脳合併症を回避することができた.

A monitoring system for tracking the electromyogram (EMG) of the vocal cords with wire electrodes embedded in an endotracheal tube was designed to identify the recurrent laryngeal nerve during thyroidectomy. Our recent experience in two cases suggests that vagal nerve activity can be correctly detected by recording of the EMG of the vocal cords using a special endotracheal tube embedded with wire electrodes.