No abstract available.
Fontan Procedure*

A very rare case of congenital adrenocortical insufficiency accompanied with ventricular septal defect, is presented. Surgical treatment together with glucocorticoid replacement therapy was performed. The patient, a 4-month-old girl with congenital adrenocortical insufficiency, had been treated with a long-term adrenocortical hormones replacement. Surgical treatment for ventricular septal defect was applied in order to reduce the risk of heart failure. The administration dose of glucocorticoid was determined according to the body surface area and chronologic change of serum cortisol. Following the surgical treatment, and with adequate glucocorticoid replacement, the patient showed a good clinical outcome. In conclusion, we showed a beneficial treatment protocol with adequate glucocorticoid replacement in open heart surgery for a case of congenital adrenocortical insufficiency.

A 44-year-old woman with heart murmur was admitted for cardiac examination. Echocardiography and cardiac catheterization including coronary angiography demonstrated atrial septal defect (ASD) and left coronary artery-main pulmonary artery fistula. At operation, the ASD was directly closed, and the proximal portion of coronary fistula was successfully ligated from the epicardial side and the fistula orifice was directly closed from inside the pulmonary trunk under the cardiopulmonary bypass. We report a relatively rare case of adult ASD with coronary-pulmonary artery fistula, with particular emphasis on the importance of consideration of the association of this anomaly in diagnosing congenital heart disease.

A 71-year-old man with early-stage esophageal cancer underwent off-pump coronary artery bypass grafting (CABG) through left thoracotomy to avoid sternotomy to allow subsequent esophageal surgery. The patient had severe double vessel coronary artery disease (the left anterior descending artery and the right coronary artery). Esophageal pull-out resection and reconstruction with the transverse colon over the sternum were planned after recovery from CABG. Therefore, we performed off-pump CABG via left thoracotomy using a saphenous vein Y-graft. Proximal anastomosis was placed in the descending aorta, and the distal anastomoses were completed with a stabilizer and an apical retraction device. Postoperative angiograms showed both grafts were patent and had suitable layout for subsequent esophageal surgery. In conclusion, off-pump CABG via left thoracotomy is an appropriate option for myocardial revascularization, if median sternotomy is contraindicated.

Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/l. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.

A 2-month-old boy developed Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after bidirectional Glenn anastomosis for hypoplastic left heart syndrome. After reexploration, only the skin was closed but the sternum left open, and continuous mediastinal irrigation using saline containing isodine was commenced at an infusion rate of 20-40ml/h. The sternum was closed on day 7 and irrigation was stopped on day 21. The patient was weaned from the ventilator 4 days later, and is currently in a good condition awaiting a Fontan operation.

Objective: Combination therapy with glecaprevir and pibrentasvir (G/P) has been shown to provide a sustained virologic response (SVR) rate of >97% in patients with chronic hepatitis C virus (HCV) infection in the first published real-world Japanese data. However, a recently published study showed that the treatment was often discontinued in patients ≥75 years old, resulting in low SVR in intention-to-treat (ITT) analysis. Thus, our aim was to evaluate real-world data for G/P therapy in patients ≥75 years of age, the population density of which is high in “rural” regions.Patients and Methods: We conducted a multicenter study to assess the efficacy and safety of G/P therapy for chronic HCV infection, in the North Kanto area in Japan.Results: Of the 308 patients enrolled, 294 (95.5%) completed the treatment according to the protocol. In ITT and per-protocol analyses, the overall SVR12 rate was 97.1% and 99.7%, respectively. The old-aged patients group consisted of 59 participants, 56 of whom (94.9%) completed the scheduled protocol. Although old-aged patients tended to have non-SVR factors such as liver cirrhosis, history of HCC, and prior DAA therapies, the SVR12 rates in old-aged patients were 98.3% and 100% in the ITT and PP analyses, respectively. Of 308 patients enrolled, adverse events were observed in 74 patients (24.0%), with grade ≥3 events in 8 patients (2.6%). There was no significant difference in any grade and grade ≥3 adverse events between the old-aged group and the rest of the study participants. Only one patient discontinued the treatment because of adverse events.Conclusion: G/P therapy is effective and safe for old-aged patients.