Kyobu geka. The Japanese journal of thoracic surgery最新文献

Mitral annular calcification (MAC) increases the risk of left ventricular rupture during mitral valve replacement (MVR). We report an 81-year-old woman with severe MAC who underwent MVR with preservation of the posterior leaflet and subvalvular apparatus, combined with selective annular debridement using an ultrasonic surgical aspirator and annular reinforcement with a bovine pericardial patch. The valve prosthesis was sewn into place with special attention to suture needle position. Our maneuver enabled safe calcification removal and implantation of an adequately sized prosthesis without left ventricular rupture or paravalvular leakage. Postoperative left ventricular function was well preserved, and the prosthetic valve showed good performance. This technique may reduce the risks of left ventricular rupture and prosthesis-patient mismatch during MVR in patients with severe MAC.

The patient is a man in his 60s with situs inversus totalis. He underwent percutaneous coronary intervention for an old myocardial infarction in his 40s and coronary artery bypass grafting( CABG) in his 60s. Through preoperative examination of CABG, moderate aortic stenosis( AS) was disclosed, and he was under outpatient follow-up. He was referred to our department because AS became severe. Since operative mortality and morbidity were high, we chose transcatheter aortic valve implantation (TAVI) as the treatment option. Fluoroscopic images were mirrored, and the delivery system was rotated 180 degrees at the time of insertion because he had situs inversus totalis. TAVI was successful, and he was discharged home without complications. In peculiar cases such as anatomical anomalies, it is crucial to perform TAVI safely. In the case of situ inversus totalis, mirroring fluoroscopic images and device inversion were beneficial.

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital anomaly, and isolated left-sided PAPVC without atrial septal defect is extremely uncommon. We report a 70-year-old man with severe mitral regurgitation, atrial fibrillation, and chronic kidney disease, in whom preoperative imaging incidentally revealed left upper pulmonary vein drainage into the innominate vein via a vertical vein. Hemodynamic evaluation demonstrated a significant left-to-right shunt [pulmonary flow/systemic flow( Qp/Qs) =1.88]. Surgical treatment consisted of direct anastomosis of the vertical vein to the left atrial appendage, combined with mitral and tricuspid annuloplasty under cardiopulmonary bypass. The postoperative course was uneventful with stable hemodynamics. This case highlights the importance of careful preoperative imaging to detect rare anomalies such as PAPVC and the need for appropriate surgical planning when concomitant valvular disease is present.

A 77-year-old woman complained of sudden chest pain and consciousness disturbance (Japan Coma Scale 3). Consciousness disturbance was improved( Japan Coma Scale 1) without paralysis on arrival at our hospital. Right upper-extremity and carotid arterial pulsation was impalpable. Contrast-enhanced computed tomography (CT) revealed dissection of the ascending aorta, and Stanford type A acute aortic dissection was diagnosed. The aortic dissection was extended into the brachiocephalic artery, which was occluded by the expanded false lumen. Head magnetic resonance imaging (MRI) identified no acute cerebral infarction. Urgent ascending aortic replacement was successfully performed with resection of the entry and removal of thrombus within the false lumen of the proximal brachiocephalic artery. The patient's postoperative course was uneventful without any neurological deficits. In acute aortic dissection with brachiocephalic artery malperfusion and neurologic symptoms, preoperative head MRI to confirm the presence or absence of acute cerebral infarction and operative resection of the entry would be useful.

A 70-year-old man with two solid pulmonary nodules in the right upper lobe and an enlarged mediastinal lymph node underwent diagnostic thoracoscopic surgery. He was diagnosed with mixed small cell carcinoma cT1cN2M0 StageⅢA and squamous cell carcinoma cT1cN0M0 StageⅠA3, received concurrent chemoradiotherapy, and achieved complete response. However, two years after the initial treatment, a mass suggestive of local recurrence was observed along the staple line of the right upper lobe. He underwent right upper lobectomy for diagnosis and treatment. The diagnosis was recurrence of small cell lung cancer, but incidentally, concurrent adenosquamous cell carcinoma was identified. After treatment for small cell lung cancer, attention should be paid to the occurrence of secondary cancers.

A 66-year-old man developed a bronchopleural fistula on postoperative day nine following video-assisted thoracoscopic right middle and lower lobectomy for right lower lobe lung cancer. An open window thoracostomy was performed on postoperative day 19. The fistula measured approximately 1 cm in diameter, and to achieve reliable closure, a right completion pneumonectomy was performed on postoperative day 56. Intraoperatively, the pleural cavity was covered with thickened granulation tissue, making anatomical identification difficult. Given the presence of infection, the procedure carried a high risk of complications such as bleeding and recurrence of bronchopleural fistula. To ensure safety, proximal vascular control was secured, and the bronchial stump was covered with an omental flap. During a three-year postoperative follow-up, no recurrence or complications were observed. Completion pneumonectomy following open window thoracostomy is extremely rare and carries high risk, thus requiring thorough preoperative planning and intraoperative preventive strategies.

Essential thrombocythemia (ET) is a rare chronic myeloproliferative disorder characterized by elevated platelet counts and increased risk of thrombosis and hemorrhage. We report the case of a 75-year-old woman with ET who underwent aortic valve replacement for severe aortic stenosis using a 21 mm Edwards INSPIRIS bioprosthesis. Her postoperative course was uneventful, without thrombotic or hemorrhagic complications. She was managed with aspirin and warfarin for antithrombotic therapy, and hydroxyurea was used to control the platelet count. Perioperative management in ET patients undergoing cardiovascular surgery is complex due to the dual risk of bleeding and thrombosis. However, standardized guidelines remain limited. This case demonstrates that with careful planning and multidisciplinary management, cardiac surgery can be performed safely in ET patients, even in elderly individuals.

Pulmonary arteriovenous malformation (PAVM) is a congenital vascular anomaly that forms a shunt between the pulmonary artery and vein. It is frequently detected incidentally in asymptomatic patients. We encountered a 69-year-old female patient with bilateral PAVMs that were incidentally detected on abdominal computed tomography( CT) performed for a detailed examination of appendicitis. Abdominal CT revealed nodular opacities with contrast enhancement in the middle lobe of the right lung and the lingular segment of the left lung. They were further examined, and a diagnosis of PAVMs measuring 14 mm and 13 mm, respectively, was made. No arteriovenous malformations were identified in other organs, and no findings suggestive of hereditary hemorrhagic telangiectasia were observed. Both lesions were located in the peripheral regions directly beneath the pleura and had a diameter of 10 mm or more. Thus, surgical resection was considered indicated, and the patient underwent thoracoscopic partial lung resection. The lesions were easily identified and resected without complications. Although percutaneous transcatheter embolization is minimally invasive, it may be difficult to perform for peripheral and large-diameter lesions. Therefore, surgery may be an effective treatment option for peripheral PAVMs, as in the case of this patient. We report a case of bilateral PAVMs that were incidentally detected and safely treated by thoracoscopic surgery.

We report a rare case of intraoperative ventricular fibrillation (VF) induced by electrocautery conduction to the pericardium during lung cancer surgery. A 59-year-old man underwent thoracoscopic left lower lobectomy. During dissection of the pulmonary ligament using an electric scalpel in coagulation mode( 30 W), the tip contacted the pericardium, resulting in VF. Immediate thoracotomy and defibrillation(20 J) successfully restored sinus rhythm. Surgeons should be aware of this rare but serious complication and ensure a defibrillator is readily available during thoracic surgery involving the pericardium.

We report our uniportal bronchoplasty procedure using the da Vinci Xi. A 4-cm skin incision was made in the axillary line at the sixth intercostal space. For this procedure, the patient's most dorsal arm was not used, and surgery was performed using the remaining three arms. The most dorsal edge of the wound was used as a camera port, and ports for the left and right hands were inserted in the anterior space. The hand controls on the console were used to change the allocation of the left and right hands and the camera. The assistant supported the surgeon by using a curved cotton ball and two long, curved suction tubes to open the surgical field and perform suction through the gap within the wound. During bronchoplasty, it is necessary to prevent the anastomotic sutures from loosening. Using a barbed suture for continuous sutures eliminates the need for assistant traction, which is useful in robotic surgery, where assistant traction is difficult. Uniportal robotic surgery, combining the minimally invasive nature of a uniportal surgery with the superior maneuverability of a robot, enables precise bronchoplasty.