Surgeons are now facing the challenge of redo valve surgery because of the increasing number of elderly individuals in Japan. The incidence of bioprosthesis dysfunction has increased among the various surgical indications of redo valve surgery due to the preference of patients and a paradigm shift in prostheses from mechanical valves to bioprostheses. Previous studies reported that the clinical outcomes of reoperative valvular surgery have markedly improved due to the maneuver of myocardial protection, cardiopulmonary bypass strategies, and appropriate safer surgical approach. The general surgical outcomes of redo valve surgery have been reported as being similar to those of primary valve surgery; however, this is still controversial and has not yet been confirmed in some developed countries. Although the unique surgical technique of transcatheter valve-in-valve implantation for bioprosthetic dysfunction is promising, redo valve surgery may become more prevalent in the future. We here reviewed the current status of reoperative valve surgery and future perspectives including catheter-based surgical interventions.

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Purpose: To investigate the morphological and functional behavior of neutrophils during and after one-lung ventilation (OLV).
Methods: We utilized an OLV rat model system and performed 3 hours of OLV followed by either re-expansion (RE) and 30 minutes of two-lung ventilation (TLV) (RE group), only two-lung ventilation (TLV group), or only OLV (OLV group). Cytoskeletal rearrangements of circulating neutrophils were assessed by determining the localization of filamentous actin (F-actin). In addition, the number of sequestered neutrophils in the lung capillary and the cytokine-induced neutrophil chemoattractant 1 (CINC-1) levels in the plasma were determined.
Results: The F-actin rimmed neutrophils in the RE group increased after RE, but did not increase in the other groups. In the RE group, the sequestered neutrophils in the ventilated lung were significantly more numerous, and the plasma CINC-1 levels were significantly higher than in the other groups.
Conclusions: Lung RE following OLV induces cytoskeletal rearrangements in circulating neutrophils and would thereby promote their sequestration in the lung capillaries. The plasma CINC-1 elevation after RE can be involved in neutrophil recruitment.

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Purpose: Five-year survival rates were widely dispersed in pN2 non-small cell lung cancer (NSCLC). The present study aims to investigate the prognosis of patients with lymph node metastasis beyond lobe-specific mediastinal regions.
Methods: A total of 654 pathologically proved N2-NSCLC patients were enrolled. All patients underwent a major pulmonary resection and radical mediastinal lymphadenectomy. Two separate groups were assigned according to the definition of lobe-specific nodal metastasis: Group LS (lobe-specific) and Group NLS (non-lobe-specific). Survival rates were calculated using Kaplan-Meier and Cox regression models.
Results: There were 376 cases in Group LS and 278 cases in Group NLS. Univariate analyses showed that the risk factors of 5-year survival were operation type, MLN positivity ratio, nodal station, nodal zone, and LS/NLS metastasis. The 5-year survival among those in Group LS was significantly better than that of Group NLS (27.5% vs. 11.7%, p <0.0001). Multivariate analysis confirmed that the grouping method of LS/NLS and number of involved nodal zones were the most prominent risk factors for 5-year survival.
Conclusion: Lymph node metastasis beyond lobe-specific lymph nodes is an independent risk factor of 5-year survival and is associated with worse prognoses for N2 NSCLC patients.

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Introduction: Gastrointestinal (GI) complications are well-recognized risks of open heart surgery. However, open heart surgery comes in different shapes and sizes with widely varying pre-operative, intra-operative and post-operative pathologies. The aim of this study was to examine the etiology and risk factors for GI complications after mitral valve surgery.
Methods: A retrospective analysis of 565 patients who underwent mitral valve surgery from 2003–2005 was performed. Prospectively collected data included preoperative risk factors, cardiac status, intra-operative data, postoperative GI complications and mortality. Survival was analyzed using log-rank analysis.
Results: In this study population, 13 patients (2.3%) had 16 GI complications after mitral valve surgery resulting in an overall mortality of 0.7%. Complications included GI bleed (n = 9), cholecystitis (n = 3), perforated diverticulitis (n = 1) and ischemic bowel (n = 3). By univariate analysis, a history of hypertension, chronic renal insufficiency (CRI), hypercholesterolemia, myocardial infarction, congestive heart failure, cardiogenic shock, emergency valve surgery, coronary artery bypass surgery and preoperative vasopressor use were each associated with an increased incidence of GI complications (p <0.05). No increased incidence was seen in patients with atrial fibrillation. On multivariate analysis adjusted for age, cardiogenic shock (OR 8.1; 95% CI, 1.9–34.8), CRI (OR 8.1; 95% CI, 2.2–30.0) and vasopressor use (OR 6.5; 95% CI, 1.3–31.0) remained significant (p <0.02). Mean survival (3.2 vs. 5.4 years) was significantly lower (p <0.05) in those with GI complications.
Conclusions: GI complications after mitral valve surgery are infrequent, with a higher incidence in those with cardiogenic shock, CRI or requiring vasopressors. Pre-operative hemodynamic instability may be a bellwether for potential GI complications and should be of more prominent concern in this cohort of patients.

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Purpose: Endovascular aneurysm repair (EVAR) is a minimally invasive treatment that is becoming standard in abdominal aortic aneurysm treatment. We examine the risk factors of death by comparing the short-term results of abdominal aortic aneurysm by open surgical repair with EVAR.
Methods: We performed elective abdominal aortic aneurysm treatment on 122 cases during the period from January 2008 to December 2009. Seventy one cases were treated with open surgical repair while 51 cases were treated with EVAR.
Results: Compared to the open surgical repair group, the EVAR group was significantly older and had a higher complication rate and past laparotomy rates. No significant difference in hospital deaths was observed between the two groups. Two deaths with thromboembolism due to shaggy aorta were observed in the EVAR group. Two cases in the open surgical repair group developed postoperative myocardial infarction and one death was observed. Both patients underwent coronary artery treatment using drug eluting stents (DES) prior to surgery.
Conclusion: Shaggy aorta has a high possibility of causing thromboembolism and EVAR should not be performed unless there is a considerable reason. In cases in which coronary artery treatment is performed with DES in recent days, EVAR is more preferable.

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Purpose: Prosthetic graft infection is a fatal complication after thoracic aorta replacement, and it is sometimes difficult to perform a prompt re-operation when the patient carries the infectious source of the graft. We evaluated the early and mid-term outcomes of aortic graft infection after thoracic aorta replacement, focusing on the timing of the surgery.
Methods: This study included eight consecutive patients with thoracic graft infection from 1997 to 2011 among 513 patients of graft replacement during this period. We performed re-graft replacement in six patients. Of these six patients, emergency surgery was performed in two and scheduled surgery was performed in two. An unscheduled emergency surgery was required in two patients during the medical treatment of the infection source. Solo medical treatment was performed in two patients.
Results: In-hospital mortality occurred in two of the eight patients (25%). Re-graft infection was not observed in the six patients who underwent re-graft replacement or the one patient who underwent medical treatment during the 1.5- to 14-year observation period.
Conclusions: Prompt re-replacement of the infected graft should be performed even when an orthotopic infection source led to the graft infection. Medical treatment might be applicable when neither an abscess nor pseudoaneurysm is observed.

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Objectives: Graft occlusion is a problem after superior vena cava (SVC) reconstruction for thoracic malignancy. Expanded polytetrafluoroethylene (ePTFE) is considered to be an optimal material for venous reconstruction.
Methods: We reviewed the hospital records of 13 patients who underwent complete resection of thoracic malignancy invading the SVC, including SVC reconstruction with ePTFE grafts. Single bypass grafting was performed in two patients (one right-sided, one left-sided) and double bypasses grafting was performed in the other patients. All patients received antithrombotic therapy after surgery. Eight patients died of recurrence or other disease during the follow-up period (range 5–41 months).
Results: Of the 24 grafts in 13 patients, graft patency was confirmed in 20 grafts in 9 patients at a mean time follow-up time of 47.8 ± 50.0 months after surgery. In the remaining four grafts in four patients, occlusion was diagnosed at a mean time of 1.25 ± 0.50 months after surgery. All obstructed grafts were left-sided bypass grafts in patients who underwent double bypass grafting, and did not result in SVC syndrome.
Conclusions: SVC reconstruction with ringed ePTFE grafts was safe and had good outcomes. In patients who underwent double bypasses grafting, the left-sided bypass grafts were susceptible to occlusion.

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Purpose: Hydatid disease is endemic in many parts of the world. Mediastinal hydatidosis is seen less than 0.1% of all hydatid diseases. We want to report our primary mediastinal hydatid cysts.
Materials and Methods: In this retrospective study, from January 2010 to December 2012, 158 patients with intrathoracic hydatid cysts were operated in our thoracic surgery clinic. Nine of 158 (5.69%) patients had mediastinal hydatid cyst. Chest X-ray and computed tomography (CT) were used as diagnostic tools.
Results: Hydatid cyst was confirmed surgically and pathologically in all the patients. Anterior mediastinal hydatid cysts and one cardiac involvement were determined in our study. While total cyst excision was performed in seven patients, partial pericystectomy could be done in two patients. In one patient, left ventricle invasion was seen and it was totally excised. Postoperative albendazole was applied to patients and there was no recurrence of disease till now.
Conclusions: Mediastinal hydatid cysts are uncommon and should be kept in mind in differential diagnosis of mediastinal cystic lesions especially in endemic regions. Surgical resection must be done and then medical therapy is needed to prevent recurrence.

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Purpose: The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, sometimes adverse events (AEs) of stapling are experienced. The aim of the present study was to retrospectively analyze AEs of stapling in thoracic surgery.
Methods: A retrospective multi-institutional review was conducted by the 27 institutions of the Central Japan Lung Cancer Surgery Study Group. Between January 2009 and December 2010, 4495 patients underwent thoracic surgery using mechanical stapling.
Results: Stapling of various tissues was performed 16403 times. Total number of AEs related to stapling was 126 (0.77%). One hundred and nine events occurred intraoperative and 17 events occurred postoperative. The AE rates ranged from 0% to 1.8%. No relationship was seen between the incidence of AE and a stapling volume of thoracic surgery.
Conclusion: We have investigated intraoperative and postoperative AEs of stapling. Generally, stapling in thoracic surgery was safe. An AE rate of stapling in thoracic surgery is not influenced by the numbers of stapling in institutions.

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We report a case with lung cancer during pregnancy, which has a very poor prognosis.A 34-year old female at 30 weeks of pregnancy came to us with a cough and right lower chest pain. Chest computed tomography revealed a mass in the right lower lung lobe and the diagnosis of adenocarcinoma cT2aN1M0 was made. We performed a right sleeve pneumonectomy, as the tumor had progressed to the right main bronchus near carina. Histological sections of the specimens revealed a poorly differentiated adenocarcinoma that infiltrated surrounding structures. The pathological stage of lung cancer was T4N2M0 stage IIIB. Immunohistochemistry findings for estrogen receptor β were positive in the nuclei of the adenocarcinoma. She had a rapid recurrence in spite of chemotherapy, and she died 7.5 months after operation. The positive estrogen receptor and hormonal condition during pregnancy might promote cancer and result in her poor prognosis.

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A 68-year-old man with severe aortic stenosis (AS) and marked left ventricular hypertrophy (LVH), underwent aortic valve replacement (AVR). Preoperative echocardiography demonstrated contact between the anterior mitral leaflet and the interventricular septum during diastole without mitral regurgitation (MR), i. e., “pseudo systolic anterior motion (SAM). " After a mechanical prosthesis had been implanted, severe mitral regurgitation MR and pulmonary hypertension occurred due to “true" SAM of the mitral valve. Despite intensive management, it was difficult to control MR in the acute phase.In the chronic phase, echocardiography revealed the resolution of both SAM and MR. It is suggested that the dramatic reduction of afterload after alleviation of valvular stenosis by prosthetic replacement and increased flow velocity in the left ventricular outflow tract (LVOT) caused SAM with MR. The risk of SAM after AVR should be considered in AS patients with marked LVH, especially in the presence of “pseudo SAM. "

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