Background: Jehovah's Witnesses do not accept blood products because of their religious belief. Our hospital takes a stance of offering absolute bloodless medicine for Jehovah's Witness patients when we perform cardiovascular surgery. Objective: The object of this retrospective study was to investigate whether our perioperative strategy for Jehovah's Witness patients undergoing cardiovascular surgery was acceptable. Methods: We retrospectively reviewed 7 Jehovah's Witness patients who underwent cardiovascular surgery between January 2013 and December 2020. The mean age of the cases was 64±10 (49-78) years. All cases involved primary and elective surgeries. Our preoperative optimization protocol for Jehovah's Witness patients included adding an erythropoiesis stimulating agent and iron to achieve a target hemoglobin level of 13 g/dl. The mean initial outpatient hemoglobin levels and preoperative hemoglobin levels were 12.3±2.2 (7.5-14.5) g/dl, 14.1±1.4 (11.1-15.2) g/dl, respectively. Our intraoperative strategy was to introduce meticulous attention to hemostasis and hemodilutional autologous transfusion and intraoperative blood salvage in each case. We also added an erythropoiesis stimulating agent and iron if needed in the postoperative period. Results: There was no in-hospital mortality among patients treated with bloodless medicine. The mean operative time, cardiopulmonary bypass time, and aortic cross clamp time were 307±103 (157-478), 137±28 (115-178), and 90±27 (68-136) min, respectively. There were no postoperative significant postoperative adverse events (myocardial infarction, stroke, reexploration for bleeding, acute kidney injury and surgical site infection）. The mean duration of follow-up was 3.7±2.6 (0.3-7.4) years and we could confirm that all patients were alive with no adverse events. Conclusions: Our perioperative strategy with absolute bloodless medicine for cardiovascular surgery in Jehovah's Witness patients seemed to be acceptable.

Ebstein's anomaly is abnormality of the right ventricular and atrioventricular valves, and the severity varies depending on the morphology. Neonatal cases are in a critical state due to severe tricuspid regurgitation and right ventricle dysfunction. We report on two neonate cases in which we performed modified Starnes surgery using a rapid two-stage approach for the most severe clinical condition of Ebstein's anomaly with pulmonary valve regurgitation. The first patient was born at 39 weeks of gestation with a weight of 3,012 g by suction delivery. On day 7 of life, she underwent main pulmonary artery ligation, bilateral pulmonary artery banding and right atrial plication. However, because lactic acidosis had progressed after surgery, she underwent an emergency modified Starnes operation on day 8 of life. The second patient was born at 37 weeks of gestation with a weight of 2,528 g by emergency caesarean section because of fetal edema. Although she underwent main pulmonary artery ligation on the day of birth, acidosis progressed, and blood circulation did not improve. For this reason, she underwent a modified Starnes operation on her first day of life.

The feasibility of surgical intervention for metastatic heart tumors is still being debated. A 76-year-old man with hepatocellular carcinoma underwent comprehensive treatment, which resulted in the only residual tumor being located in the heart. Therefore, surgical intervention was considered. The surgery involved complete removal of the right ventricular wall, including the tumor and an additional 5 mm of surrounding tissue, and formation of the right ventricle. The pathological diagnosis was positive at the cut end, but there has been no recurrence of the tumor within the heart after 10 months of surgery.

Cardiac hemangioma is a rare, primary, benign cardiac tumor usually diagnosed in young or middle-aged patients. Diagnosis in elderly patients is even rarer. An 80-year-old woman was referred to our hospital with intermittent and worsening left chest discomfort. Transthoracic echocardiography revealed an immobile tumor with broad attachment in the lumen to the anterior wall of the right ventricle. Contrast-enhanced computed tomography revealed an irregular, oval defect in contrast enhancement in the right ventricle. T2-weighted magnetic resonance imaging revealed an oval tumor attached to the anterior wall of the right ventricle. Complete resection of the tumor, including myocardium at the tumor attachment, was performed under cardiopulmonary bypass. The resulting defect in the anterior wall of the right ventricle was repaired with a bovine pericardial patch. Postoperative histopathological examination resulted in the diagnosis of benign cardiac cavernous-capillary type hemangioma. The patient was discharged home on postoperative day 12 without major complications. She has since been followed-up at our outpatient clinic, and has been doing well with no evidence of recurrence as of 3 years postoperatively. We report our experience with this rare case.

A 79-year-old man with severe aortic stenosis was referred to our department for surgical treatment. For the surgery, aortic valve replacement was performed with a bioprothetic valve (INSPIRIS RESILIA 23 mm, Edwards Lifesciences) at the supra annular position and proceeded without any particular problem till declamping. But weaning from cardiopulmonary bypass became difficult, and transesophageal ultrasonography showed the appearance of mitral valve systolic anterior motion (SAM), severe MR and LVOT. We tried to use with medical treatment (betablocker medications, cathecholamine intravenous injection and fluid administration), but the hemodynamics were unstable, so we decided to surgically treat the mitral valve with a second pump. We performed the Alfieri Stitch (edge to edge) for mitral valve systolic anterior motion (SAM) and severe MR, with no leakage detected in the leak test. Transesophageal ultrasonography revealed mild MR and the disappearance of SAM and LVOTO. The weaning from cardiopulmonary bypass was easy, and the operation was completed. Postoperative hemodynamics were good. Two weeks after the operation, transthoracic ultrasonography showed no problem. The patient was discharged 20 days after the operation. After discharge, the patient is doing well without recurrence of mitral valve SAM or worsening of MR.

A 75-year-old woman underwent PTMC and TAVI for heart failure due to severe MS and AS 6 years ago. The patient did not receive surgical treatment because of the patient's history of ITP, depression, and Alzheimer's disease. The patient had been suffering from heart failure due to re-exacerbation of valvular heart disease 3 months earlier. We decided to perform surgery because of the difficulty of catheter treatment. Preoperative examination revealed narrowing of the mitral annulus, and there was a risk of interference with TAVI in conventional MVR. Therefore, we used a composite graft with a biological valve to perform MVR in a supra-annular position. We achieved good results without interference with the TAVI. Although several methods of mitral valve replacement for narrow valve annulus have been reported, a technique similar to this have been previously reported as the “Bio-chimney method” . It can be an effective treatment; however, the number of cases is small and the method's long-term results require further investigation.

Cardiac Surgery Advanced Life Support (CALS) has been introduced as a cardiopulmonary resuscitation (CPR) after cardiac surgery since 2006, and has been recommended by Society of Thoracic Surgeons (STS) since 2017 and by the AHA (American Heart Association) guideline since 2020. The modified CALS protocol, which was partially revised to fit Japanese medical situations, was introduced to our hospital in 2019. Of 550 patients who underwent cardiac surgeries from April 2019 through May 2021, 6 patients (1.1%) (mean age: 51.8±27.2 years.) were resuscitated by the CALS protocol. We describe a case of repeated ventricular fibrillation (VF) due to R on T caused by ischemia-reperfusion injury. A 67-year-old man underwent aortic root replacement, total aortic arch repair, and coronary artery bypass surgery for a Stanford A type acute aortic dissection with right coronary artery malperfusion and cardiac tamponade. On the day of surgery, the patient was in VF and returned to sinus rhythm by prompt defibrillation by the ICU staff, but VF repeated every few minutes. Repeated VF was resolved by timely resternotomy, cardiac massage, and percutaneous extracorporeal circulatory support. Chest compression was avoided and the patient was discharged without neurological complications. The CALS protocol has enabled us to perform rapid CPR and resternotomy for cardiac arrest after cardiac surgery.

We report the case of a patient with severe tricuspid regurgitation associated with congenital right-sided defect of the pericardium. The patient was a 79-year-old man with a 12-year history of chronic atrial fibrillation. He was referred to our hospital because of exertional dyspnea and lower leg edema. The results of a thorough examination established heart failure due to severe tricuspid regurgitation caused by right heart dilatation. Tricuspid valve repair (Physio Tricuspid Annuloplasty Ring 28 mm ＋ right ventricular papillary muscle approximation＋anterior-septal commissure plication＋neochordae reconstruction), mitral valve repair (Physio II Annuloplasty Ring 34 mm) and left atrial appendage closure was performed. At surgery, the right atrium and ventricle were remarkably enlarged. The right-sided pericardium was widely absent and the right atrium herniated into the right thoracic cavity. These findings suggested that congenital right-sided defect of the pericardium resulted in a dilatation of the right atrium with subsequent severe tricuspid regurgitation.

The transfemoral (TF) approach is the most common and least invasive method of transcatheter aortic valve implantation (TAVI; TF-TAVI), but it is sometimes difficult to perform in cases with poor access. In addition, previous aorta replacement procedures have been associated with difficulty passing the device because of leg diameters, bends, stenosis of anastomoses and narrow elephant trunks. We herein report a case of successful TAVI with additional TEVAR to manage difficult access after thoracoabdominal aorta replacement. An 80-year-old woman had undergone thoracoabdominal aorta replacement surgery 13 years earlier. During postoperative follow-up, aortic stenosis was observed, which gradually worsened, and she was admitted to the hospital for surgery. Echocardiography showed a peak velocity of 4.9 m/s, mean PG of 57 mmHg, and AVA of 0.53 cm², indicating severe aortic stenosis. Computed tomography showed LAD stenosis and an aortic valve annulus area of 379 mm². In addition, an elephant trunk was inserted at the proximal anastomosis of the artificial vessel, and folded toward the foot, and stenosis was suspected, so we decided to perform IVUS at the time of surgery. The patient underwent surgery via a femoral approach under local anesthesia and sedation. Since the wire could not pass the elephant trunk, pull through performed via the left hand, and IVUS was passed through. There was stenosis at the anastomosis and elephant trunk, TEVAR was performed for covered with the anastomosis and elephant trunk to prevent balloon shifting. TAVI was then completed without issue. Additional surgical techniques to secure access after aortic replacement and elephant trunk placement were helpful for completing TF-TAVI.

We describe two cases of proximal anastomotic pseudoaneurysms resulting from ascending aortic or total arch replacement for type A acute aortic dissection, which were further presumed to be caused by BioGlue-induced tissue degeneration. BioGlue was applied into the proximal false lumen to reattach the dissected layers of the aortic wall in both cases. Case 1: A 66-year-old man underwent an emergent total arch replacement for type A acute aortic dissection. Eighteen months after surgery, he experienced chest pain and general fatigue. A chest computed tomography (CT) revealed a proximal anastomotic pseudoaneurysm, and consequently, a re-ascending aortic replacement was performed. Case 2: A 78-year-old woman underwent an emergent ascending aortic replacement for type A acute aortic dissection. Two years after surgery, she was admitted to our hospital due to severe leg edema. Chest CT showed a proximal anastomotic pseudoaneurysm that compressed the pulmonary artery, subsequently a re-ascending aortic replacement was performed for the same. Intraoperative findings showed that the proximal anastomosis site was disrupted on the side of the noncoronary sinus of Valsalva, and there were chronic thrombus and residual BioGlue in the false lumen in both the cases. Additionally, pathological findings revealed nucleus loss and necrosis of smooth muscle cells, and degenerative changes in elastic fibers in the all layers of the aortic wall. Appropriate use of BioGlue and careful selection of indicated patients are crucial for improving long-term outcomes. Moreover, it is necessary to follow-up patients who underwent aortic surgeries using BioGlue.

An 88-year old woman, who had been followed up in our center with a dilation of pulmonary artery and pulmonary valve regurgitation, was admitted with progressive exertional dyspnea and ambulant edema. Several examinations demonstrated the pulmonary artery dilated over 55 mm with pulmonary hypertension (mean pressure 39 mmHg) and significant pulmonary valve regurgitation with moderate to severe grade. No congenital heart anomaly was identified. Surgery was indicated because of progressive dilation of the pulmonary artery and worsening heart failure. We performed graft replacement of the pulmonary artery with a Y-shaped Dacron graft and pulmonary valve replacement using a bovine bioprothetic valve through a median sternotomy under cardiopulmonary bypass. Each pulmonary valve leaflet seemed to be normal, and the pulmonary valve regurgitation was caused by shallow coaptation due to dilation of the sinotubular junction. Pathological examination of the excised aneurysms revealed true aneurysmal formation with no specific inflammatory changes. Although her postoperative course was relatively complicated requiring prolonged ventilation support, she was transferred on postoperative day 56th for rehabilitation program. Her physical condition returned to well 6 months after postoperatively.

Cerebral microbleeds (CMBs) are asymptomatic small bleeds detected on T2^*-weighted magnetic resonance imaging. Some studies have reported associations between the number of CMBs and the risk of intracerebral hemorrhage (ICH). Here, we present the case of a patient who underwent total debranching thoracic endovascular aortic repair (hybrid TEVAR) for a thoracic aortic aneurysm with multiple CMBs and a history of ICH, avoiding the risk of de novo ICH. The intraoperative and postoperative courses were uneventful, and no ICH reccurred. Hybrid TEVAR is effective for an aortic aneurysm with CMBs and avoids intraoperative ICH.

We report a rare case of infected pseudoaneurysm associated with horseshoe kidney post graft replacement of the abdominal aorta. A 78-year-old man with chronic kidney disease and a surgical history of Y-shaped graft replacement in the abdominal aorta 25 years earlier, was hospitalized with the chief complaints of persistent fever and appetite loss. Computed tomography showed a 60 mm-sized pseudoaneurysm around the proximal anastomosis site accompanied by peri-prosthetic high fatty tissue density and a horseshoe kidney overlying the abdominal aorta. An accessory renal artery supplying the right kidney originated from the right leg of the previous Y-graft. Infectious pseudoaneurysm was strongly suspected because intensive medical treatment was not effective, and positron emission tomography-computed tomography demonstrated high fluorodeoxyglucose accumulation around the proximal anastomosis site. Open surgery was thus performed through a re-laparotomy approach. After obtaining a good surgical view after transection of the horseshoe kidney isthmus using the Liga-Sure Vessel sealing system, radical resection of the suspected infectious tissue and I-graft replacement with omental flap coverage were safely performed. The previous reattached accessory artery was left untouched because infection seemed to be out of range. Streptococcus dysgalactiae/canis was detected via postoperative culture test from the resected felt strip that was used in the previous vascular surgery. The postoperative course was uneventful without recurrence of infection or worsening of renal function; the patient was discharged on postoperative day 34 after completion of a sensitive antibiotics protocol.

Gluteal compartment syndrome (GCS) is one of the rare complications of abdominal aortic aneurysm (AAA) repair. GCS requires prompt diagnosis and early treatment. Here, we report a case of GCS after AAA repair. A 79-year-old male underwent an endovascular abdominal aortic repair (EVAR) with right internal iliac artery embolization for an asymptomatic 5.7-cm right common iliac artery aneurysm (CIAA) at our hospital 6 years ago. Follow-up computed tomography (CT) revealed an enlarged CIAA due to type II endoleak from the lumbar arteries. Open surgical repair was performed, and open ligation of the culprit lumbar artery causing the type II endoleak was attempted but the surgical plan was converted to prosthetic graft replacement due to strong intra-abdominal adhesions. The patient complained of severe pain in the left buttock and presented with swelling in the left buttock and left lower paresthesia 2 days postoperatively. CT revealed swollen gluteus muscles, and the left gluteal compartment pressure was measured as 110-120 mmHg. We diagnosed a GCS and performed surgical decompression and debridement of the left gluteal compartments urgently. Postoperatively, renal function gradually improved although the patient required hemodialysis, resulting in left sciatic nerve palsy.

A 62-year-old woman presented with impending rupture of the celiac artery aneurysm. The enhanced CT revealed two aneurysms in the celiac artery, one 18 mm with prominent lesion on the proximal side and the other 12 mm on the distal site, and increased CT value around the aneurysms. There was poor development of collateral blood circulation from the superior mesenteric artery to the hepatic artery. Coil embolization for celiac artery aneurysms was the preferred approach due to the risk of the injury to the aneurysms. Insufficient collateral circulation from the superior mesenteric artery indicated that bypass to the hepatic artery and splenic artery were necessary. The bypass grafting from the abdominal aorta to the hepatic artery and splenic artery was performed using the great saphenous vein, and coil embolization was then performed on the celiac artery aneurysm. Postoperative CT showed that the grafts were patent and there was no blood flow in the celiac aneurysm. If endovascular treatment alone or surgical treatment alone is not feasible, the hybrid treatment of surgical revascularization and coil embolization of the celiac aneurysm can provide a relatively safe and minimally invasive treatment for celiac artery aneurysms.

Coronary artery bypass grafting (CABG) is one of the most important procedures in cardiovascular surgery. We have launched a questionnaire survey on how the U-40 trainees try to acquire the skill of CABG and the strategies for CABG in their institutes. We report and discuss the results of this investigation.