論文

Patients with bicuspid aortic valves are prone to aortic complications. Here, we present a 72- year- old man for whom prosthetic replacement of a stenotic bicuspid aortic valve had been performed 2004. After surgery, the patient was followed up as an outpatient with yearly echocardiographic and computed tomographic examinations. A recent routine checkup revealed an ascending aortic diameter of 45 mm, mild prosthetic valve regurgitation, moderate- to- severe stenosis, and a peak pressure gradient of 47 mm Hg. Eight months later the patient complained of dyspnea. Echocardiography showed severe aortic regurgitation and stenosis (peak pressure gradient, 58 mm Hg) and an intimal flap in the ascending aorta with jet blood flow towards the posterior aortic wall. Computed tomography showed localized dissection and dilation of the ascending aorta (56 mm in diameter). Emergency aortic valve re- replacement and partial aortic arch replacement were performed. A dissecting entry tear was found during surgery at the posterior aortic wall. This case of structural valve dysfunction with rapidly progress ascending aortic enlargement and aortic regurgitation suggests that aggressive surgical treatment should be considered in such cases.

Background In acute type A aortic dissection (AADA) patients, total arch replacement (TAR) using the frozen elephant trunk (FET) technique has been adopted in emergencies to promote distal false lumen (FL) thrombosis. However, TAR is technically demanding and is associated with prolonged operative time and increased intraoperative blood transfusion. We previously reported the branched stented anastomosis frozen elephant trunk repair (B-SAFER) technique. Comparative data versus conventional TAR (cTAR) adjusted for disease severity remain limited. Here we compared the early surgical outcomes of TAR using B-SAFER versus cTAR in AADA. Methods This retrospective, multicenter, nonrandomized study included patients with AADA and a patent FL who underwent emergency TAR using B-SAFER (n = 63) and cTAR (n = 75). Propensity score matching based on EuroSCORE and JapanSCORE identified 48 matched pairs. After matching, 16 patients (33%) in the comparator group underwent conventional TAR without an FET device because of institutional practice patterns or device-related constraints. Results The 30-day mortality was 7.3% overall (7/96), with no significant difference between the groups (6.2% for B-SAFER vs 8.3% for cTAR; P > .999). Spinal cord ischemia occurred in 0% versus 4.2% ( P = .153). All operative time metrics were significantly shorter with B-SAFER (all P ≤ .024). Transfusion requirements for red blood cells, fresh frozen plasma, and platelets were all significantly lower (all P < .001). Conclusions In propensity score–matched patients with AADA, TAR using B-SAFER was safe and reproducible, with reduced operative times and transfusion requirements compared to cTAR.

Purpose: The superior septal approach offers improved mitral valve exposure compared to the right-sided left atriotomy or transseptal approach. However, the risk of postoperative sinus node dysfunction remains controversial, with limited data in the context of right mini-thoracotomy. Methods: This retrospective study included 155 patients (64 women; mean age, 60.8 ± 13.4 years) who underwent mitral valve surgery via right mini-thoracotomy between November 2016 and August 2023. Indications included degenerative mitral regurgitation (94.8%) and mitral stenosis (5.2%). Patients were divided into 2 groups: the conventional minimally invasive mitral valve surgery (CM) group (n = 47), using the right-sided left atriotomy, and the drawer-case technique (DCT) group (n = 108), using the superior septal approach. Demographic, intraoperative, and outcome data were analyzed. Results: Baseline characteristics were similar between groups. There were no significant differences in valve repair techniques or postoperative echocardiographic findings. Postoperative junctional rhythm occurred in 6 patients (CM group) and 21 patients (DCT group); all patients with preoperative sinus rhythm returned to sinus rhythm postoperatively. Conclusion: The superior septal approach does not increase the risk of persistent junctional rhythm in right mini-thoracotomy and is a safe and effective option for mitral valve surgery.

We report the case of a child with right pulmonary agenesis, congenital tracheal stenosis, and atrial septal defect (ASD). At age 2 years, an intrathoracic tissue expander was placed to reduce tracheal compression from mediastinal shift and to enable subsequent atrial septal defect closure. At age 5 years, a right atrial mass was incidentally detected along with right atrial compression caused by the expander. Emergency mass resection was performed, and the mass was diagnosed as a thrombus. The tissue expander was subsequently deflated and removed to prevent further compression. The patient had no recurrence of thrombus or respiratory symptoms during 8-year follow-up.

Surgeons have been reluctant to adopt minimally invasive combined aortic and mitral valve surgery through a minithoracotomy because of its complexity and prolonged cardiopulmonary bypass and aortic cross-clamping times. Our technique was designed to provide a close and frontal surgical visual field without the need for long-shafted specialized surgical instruments, thereby allowing a standardized and well-visualized surgical visual field in many cases. Here we describe the implementation of our minimally invasive combined aortic and mitral valve surgical procedure through a right minithoracotomy facilitated by the superior septal approach for mitral valve access.

Severe true lumen narrowing in chronic dissecting thoracoabdominal aortic aneurysms (dTAAAs) can compromise accurate fenestration alignment and hinder reliable bridging of the renovisceral branches. We evaluated the safety and feasibility of fenestrated endovascular aortic repair using a physician-modified endograft incorporating a visceral segment interrupted constraining suture. This permanent diameter-constraining modification is intended to stabilize the endograft within a narrowed true lumen and improve target vessel access. Sixteen patients with chronic dTAAA underwent elective repair using a low-profile Zenith Alpha Thoracic device. All 60 renovisceral branches were successfully bridged, resulting in 100% intraoperative technical success, defined as completion of the planned procedure with aneurysm sac sealing, with no 30-day mortality. Three patients required early reintervention for endoleak (1 type IC; 2 type IIIC). Follow-up imaging through 12 months demonstrated durable aneurysm exclusion and sustained branch patency. In this early experience, a visceral segment interrupted constraining suture provided reproducible diameter control and facilitated target vessel access in complex dTAAA treated by physician-modified endograft-based fenestrated endovascular aortic repair.