We have performed trans-axillary aortic valve replacement (TAX AVR) as a new minimally invasive approach in 5 patients with aortic regurgitation since September 2012. The mean age was 63 years (range 25-84 years). TAX AVR was performed through 7 cm skin incision along the right anterior axillary line, and small 4th intercostal thoracotomy. Cardiopulmonary bypass was established through the femoral artery and vein. Intra-thoracic procedures were performed under direct vision, or videoscopic assistance with the aid of minimally invasive surgical apparatus. The mean operative time was 312±44 min, cardiopulmonary bypass 217±38 min, and cross-clamp 139±22 min. The mean ventilation time was 4.2±6.1 h, and length of post-operative hospital stay was 14.8±0.9 days. There was no re-operation for bleeding, or conversion to median sternotomy. TAX AVR can avoid sternotomy, transection of rib, and sacrifice of internal thoracic artery. The postoperative wound was unrecognizable unless the right arm was raised. This approach may promise patients' early rehabilitation and better cosmetic results.

We present a rare case of stent graft infection. A 69-year-old man, who had undergone endovascular repair of an abdominal aortic aneurysm with an Inoue stent graft 5 years previously, was admitted with high-grade fever. An abscess around an abdominal aortic aneurysm was found on abdominal computed tomography (CT) and he was given a diagnosis of stent graft infection. The stent graft was removed and vascular reconstruction was performed using a Gelweave graft bonded with rifampicin. The graft was then covered with the greater omentum, and he was discharged on the 27th postoperative day.

A retrospective review was performed on 43 patients on hemodialysis undergoing valve surgery between May 1999 and August 2004. Ages ranged from 36 to 80 years (mean, 63.8 years). Twenty aortic, 9 mitral, 8 aortic and mitral and 6 valvuloplasties were performed. Twenty-three aortic mechanical valves, 5 aortic bioprosthetic valves, 13 mitral mechanical valves and 4 mitral bioprosthetic valves were implanted. Twenty-five of the 28 aortic valve replacement were hypoplasia of the aortic valve ring. There were 3 hospital deaths (heart failure, pneumonia and sepsis). There were 10 late deaths (2 heart failure, 2 pneumonia, wound infection, cerebral infarction, 2 cancer, arteriosclerosis obliterans and unknown death). Survival at 1, 3 and 5 years was 81%, 74% and 47%. There were three documented major bleedings or thromboembolisms in the 29 patients with mechanical valves (10%) and none in the 9 patients with bioprosthetic valves (0% no significance). Three reoperations were performed for premature degeneration of bioprosthetic valve (19, 24 and 50 months) due to accelerated calcification. These results demonstrate that the prosthetic valve-related major bleedings and strokes in hemodialysis patients are similar for both mechanical and bioprosthetic valves, and that bioprosthetic valves will undergo premature degeneration. Therefore, preference should be given to mechanical valve prostheses in hemodialysis patients.

Endoventricular circular patch plasty (the Dor procedure) has been demonstrated to improve outcome in patients with ischemic cardiomyopathy. However, in some of them congestive heart failure (CHF) occurred during follow-up. This study examined the effects of the Dor procedure on the long-term survival and predictors of CHF after this procedure. Hemodynamic and clinical results were analyzed and predictors of CHF were examined. Postoperative ESVI in the CHF group was larger than that in the non-CHF group. The delayed MR rate was greater following the CHF group (82.4%) compared to the non-CHF group (19.2%). Despite mitral valve repair (N=8), 3 patients had delayed MR. All of them were greater than MR³. Hemodynamic and clinical results were improved by the Dor procedure. However, cardiac events were usually occurred during the follow-up. The predictor of CHF was delayed MR. Therefore, patients with preoperative MR should be treated. If preoperative MR is greater than 3, there will be MR recurrence cases after MVP only. Therefore, patients with preoperative MR (3 or 4) should be treated by alternative surgical procedures.

To improve the long-term clinical results of coronary artery bypass grafting, we evaluated our graft selections and the designs that were used, in relation to the quality of the anastomoses and patient backgrounds. We retrospectively reviewed the records of 505 patients who underwent isolated coronary artery bypass grafting involving more than 3 vessel reconstructions between May 1999 and March 2007. Neither the selection of a saphenous vein graft nor that of an internal thoracic artery graft was a statistically significant cardiac event factor. The cardiac event-free rates (at 1 and 5 years) according to anastomotic site were as follows : a) 92.9% and 76.6% for a radial artery graft and 93.2% and 83.9% for a saphenous vein graft at the right coronary artery ; b) 93.0% and 70.3% for a radial artery graft and 95.1% and 80.4% for a saphenous vein graft at the distal right coronary artery ; c) 94.5% and 77.8% for a left internal thoracic artery graft and 93.0% and available for a right internal thoracic artery graft at the left anterior descending artery ; d) 96.5% and 79.8% for a radial artery graft, 93.0% and 78.0% for a saphenous vein graft, and 91.3% and 75.6% for an internal thoracic artery graft at the left circumflex artery. Significant cardiac event factors were dialysis (risk ratio, 5.28 ; p<0.001), the use of a right gastroepiploic artery graft as the inflow blood vessel of a radial artery graft (risk ratio, 5.75 ; p=0.02), and off-pump coronary artery bypass grafting (risk ratio, 1.62 ; p=0.03). As a tendency toward more frequent early-stage cardiac events among patients with radial artery grafts was confirmed, careful follow-up is important for this group of patients. Right gastroepiploic artery grafts should be chosen carefully with full consideration of the anastomotic site quality and the flow demand, as the blood supply capability of such grafts is limited. For dialysis patients, although the mid-term clinical results are still being evaluated, a saphenous vein grafts have bwer early-stage of cardiac events. In younger patients, off-pump bypass is not the only treatment method available, and revascularization with extracorporeal circulation can reliably achieve good long-term results. To improve the long-term clinical results for coronary artery bypass grafts, graft selection and design should be carefully considered on a case-by-case basis. The quality of the anastomotic site and the patient background are important factors, especially with regard to the selection of a saphenous vein graft or a right gastroepiploic artery graft. A radial artery graft should be selected for use in relatively young patients because of its superior patency. Off-pump bypass may not necessarily be the treatment of choice in some cases because revascularization using extracorporeal circulation can reliably achieve better long-term results.

Primary cardiac tumors are rare. Myxoma is the most common type of benign cardiac tumor and papillary fibroelastoma (PFE) is the second most common. We report a case of coexisting left atrial myxoma and aortic valve PFE. A 77-year-old Japanese woman with a left atrial mass was referred to our hospital for further diagnostic evaluation and surgical treatment. The mass was detected by coronary computed tomography, which was performed by her general practitioner. Investigation with an echocardiogram revealed a mass on the fossa ovalis, extending into the left atrium. Intraoperative transesophageal echocardiography (TEE) showed another mass attached between the left coronary cusp (LCC) and the right coronary cusp of the aortic valve. After cardiopulmonary bypass and cardioplegic arrest, we performed an aortotomy, and observed the aortic valve. We found a mobile mass on the LCC and resected it. After left atriotomy, a left atrial myxoma was identified and resected, together with its margin. Postoperatively, sinus bradycardia, sinus pauses, and atrial fibrillation tachycardia were identified. Therefore, we implanted a permanent pacemaker on the 29th postoperative day. The patient was discharged on the 38th postoperative day. Simultaneous existence of two different primary cardiac tumors is rare. We believe that preoperative and intraoperative TEE in patients with cardiac tumors is important.

Objective : The objective of this study was to assess the safety and efficacy of left atrial appendage (LAA) amputation during cardiovascular surgery. Methods : Fifty-seven patients underwent LAA amputation using a stapler from 2016 to 2017. The presence of remnant LAA was estimated by transesophageal echocardiography (TEE). Results : All LAA amputations were performed with the heart beating, without collapse. Additional amputation for remnant LAA was required in 14 patients. Sutures were needed to control bleeding in 7 patients. There was one case in which the coronary artery ended up being clamped with the LAA. The average duration for LAA amputation was 6.1±3.2 (1.5-15.2) min. There were 25 cases with postoperative atrial fibrillation (POAF), one case of cerebral infarction without POAF and one case of re-exploration for bleeding. Three patients died during hospitalization. Conclusion : LAA amputation using a stapler does not require cardiac arrest, and rarely requires an extended operation time. However, sufficient caution is required as there is the possibility that the coronary artery is obstructed and that remnant LAA is present.

Aims: This study aimed at investigating the status of polypharmacy and the experience and perception of bereaved family members of patients with advanced cancer regarding the burden of oral medication. Methods: Self-administered questionnaires were mailed to 303 bereaved family members of patients with advanced cancer, and 102 valid responses were analyzed (response rate, 33.7%). Results: The number of patients in the polypharmacy group (patients taking six or more tablets at a time) was 65 and that in the non-polypharmacy group (patients taking less than six tablets at a time) was 37. The percentage of bereaved family members who felt that the oral administration burden of patients was significantly higher in the polypharmacy group (43.1% vs. 10.8%, p<0.01). The results of the analysis indicated that the bereaved families wanted to reduce the number of tablets taken at a time for alleviating the burden of polypharmacy. The bereaved families of patients in the polypharmacy group were greatly concerned that the number of oral medications was too large. They also expressed the need for medical staff from whom they could seek explanation and counseling regarding the oral medication of patients. Conclusion: It is suggested that medical staff need to be fully aware of the concerns of patients’ families regarding drugs besides checking the compliance status.