Japanese Journal of Cardiovascular Surgery Vol.29, No.1

Originals

Usefulness of Percutaneous Phrenic Nerve Stimulation for Assessing Phrenic Nerve Injury after Pediatric Cardiac Surgery 　　Y. Hachiro, et al.…1

Usefulness of Percutaneous Phrenic Nerve Stimulation for Assessing Phrenic Nerve Injury after Pediatric Cardiac Surgery

(Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan and Children's Hospital and Medical Center＊, Hokkaido, Japan)

Yoshikazu Hachiro Seiya Kikuchi Masayoshi Ito

Takeshi Kobayashi Kazuhiro Takahashi Toshihisa Matsui

Tomio Abe Shinji Sato＊

Six (1.2%) of 501 patients sustained phrenic nerve injury during operation for congenital heart disease at our institutions between 1992 and 1998. The diagnosis was confirmed by percutaneous stimulation of the phrenic nerve. All but 1 patient were less than 9 months old, and the average weight was 3.6kg. All 6 patients underwent diaphragmatic plication and were extubated by 7 days after operation. Percutaneous stimulation of the phrenic nerve allowed direct assessment of phrenic nerve function which was difficult to detect by clinical and radiological evidence. This method can be non-invasively used at the bedside to facilitate early and accurate diagnosis of phrenic nerve palsy.
　Jpn. J. Cardiovasc. Surg. 29：1-4(2000)

Risk Factors and Treatment for Mediastinitis in Internal Mammary Artery Grafting, with Particular Regard to Diabetic Patients 　　Z. Masuda, et al.…5

Risk Factors and Treatment for Mediastinitis in Internal Mammary Artery Grafting, with Particular Regard to Diabetic Patients

(Department of Cardiovascular Surgery, Okayama University Medical School, Okayama, Japan and Department of Cardiovascular Surgery, Cardiac Center Sakakibara Hospital＊, Okayama, Japan)

Zenichi Masuda Takato Hata＊ Yoshimasa Tsushima＊

Mitsuaki Matsumoto＊ Souhei Hamanaka＊ Hidenori Yoshitaka＊

Kotaro Fujiwara＊ Yasumori Sodenaga＊ Hiroshi Furukawa＊

Hitoshi Minami＊

The internal mammary artery (IMA) has been widely used in CABG due to the excellent long-term results. However, the extensive use of bilateral IMA grafting has been believed to increase operative morbidity and mortality. This study was designed to determine if bilateral IMA grafting in diabetic patients increased the likelihood of mediastinitis. We analyzed the data of 386 consecutive patients who underwent isolated CABG in 1992 to 1996. The definitions of sternal wound complications are as follows, (１) mediastinal dehiscence and (２) mediastinal wound infection. Subtypes include superficial wound infection and deep wound infection (mediastinitis). Among these patients 97 received unilateral IMA grafts and 289 did bilateral IMA grafts. Mediastinitis did not occur in any subjects. The occurrence rate of mediastinal dehiscence and superficial wound infection was 7.2% (7/97) for bilateral IMA grafting, 7.3% (21/289) for unilateral IMA grafting. No patients died of wound complications. The occurrence rate of mediastinal dehiscence and superficial wound infections were 12.0% (4/33) for bilateral IMA grafting in diabetic patients, 12.0% (14/117) for unilateral IMA grafting in diabetic patients. That of this complications was 4.7% (3/64) for bilateral IMA grafting in non-diabetic patients, 4.1% (7/172) for unilateral IMA grafting in diabetic patients, without significant differences in wound complication. Bilateral IMA grafting in diabetic patients carried no great risk of mediastinitis, but diabetes mellitus itself was a great risk for mediastinitis.
　Jpn. J. Cardiovasc. Surg. 29: 5-9 (2000)

Treatment of Vascular Graft Infection after Operation for Thoracic Aortic Aneurysms 　　H. Inada, et al.…10

Treatment of Vascular Graft Infection after Operation for Thoracic Aortic Aneurysms

(Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kawasaki Medical School, Kurashiki, Japan)

Hiroshi Inada Taiji Murakami Hisao Masaki

Ichiro Morita Atsushi Tabuchi Atsuhisa Ishida

Koichi Endo Daiki Kikukawa Takashi Fujiwara

During 23 years, 224 cases underwent graft replacement of thoracic aortic aneurysms at our institution. Of these, 14 cases suffered postoperative vascular graft infection. Out of the 14 cases, 13 cases had sternal or mediastinal infections, and one case showed sepsis without these deep wound infections. Six cases were positive by blood culture. We thought that sternal or mediastinal infections had a high possibility of contamination of vascular grafts and that cases with these deep wound infections should be treated as cases of graft infection. Reoperation was done urgently soon after the diagnosis of infection was made. When the wound was not so deep, only debridement was performed. In addition to debridement, continuous irrigation through a chest tube and, recently, pedicled omental flap placement were done, when the wound was deep. Except for the one case without deep wound infection, 13 cases were reoperated. There were 4 hospital deaths; 3 operated cases and the nonoperated case, due to lack of control of their infection. Blood culture were positive in all these four cases. The other 10 cases were discharged from hospital without infection. Infection of vascular grafts after operation for thoracic aortic aneurysms is a serious complication and urgent reoperation should be done. However it should be noted that the mortality rate of cases with positive blood culture is high.
　Jpn. J. Cardiovasc. Surg. 29: 10-16 (2000)

Case Reports

Surgical Treatment for Type IIIb Aortic Dissection in Association with a True Aortic Aneurysm 　　H. Yasumoto, et al.…17

Surgical Treatment for Type IIIb Aortic Dissection in Association with a True Aortic Aneurysm

(Second Department of Surgery, Miyazaki Medical College, Miyazaki, Japan and Miyazaki Medical Association Hospital＊, Miyazaki, Japan)

Hirosi Yasumoto Kunihide Nakamura Seiji Nakashima

Takahiro Hayase Eisaku Nakamura Yasunori Fukushima＊

Toshio Onitsuka

DeBakey IIIb aortic dissection associated with thoracic aneurysm was successfully operated upon in a 59-year-old man. The patient had sudden onset of severe back pain and pain in the left lower extremity and dissection associated with thoracic aneurysm was diagnosed. During the operation, we used partial cardiopulmonary bypass support with cannulation of the pulmonary and femoral artery. The entry of the dissection was in a true aneurysm of the descending aorta, and it was replaced with a 22mm Hemashield prosthetic graft. Aortic dissection, with entry in the true aneurysm is rare and is of high risk for rupture.
　Jpn. J. Cardiovasc. Surg. 29: 17-20 (2000)

Lower Mini-Sternotomy for Direct Coronary Artery Bypass on the Beating Heart 　　T. Yamamoto, et al.…21

Lower Mini-Sternotomy for Direct Coronary Artery Bypass on the Beating Heart

(Department of Thoracic and Cardiovascular Surgery, Juntendo University, Tokyo, Japan)

Taira Yamamoto Yasuyuki Hosoda Shiro Sasaguri

Kenji Takazawa Masahiro Goto Shiori Kawasaki

Motoshige Yamasaki Hiroshi Sato Tomonobu Fukuda

Although left anterior descending coronary artery (LAD) grafting with a left internal thoracic artery (ITA) on a beating heart via a small left anterior thoracotomy (LAST) has become widely accepted, significant limitations exist due to the limited surgeon experience, smallness of exposure, thus making harvesting of the ITA, visualization of the surgical field and anastomosis quite difficult. Patients often have significant pain and wound complications postoperatively. A lower mini-sternotomy approach in 4 patients was performed from December 1998 through January 1999. Results: The length of mini-sternotomy incision is 7 to 14cm. These operations were accomplished without morbidity or mortality. No patients required intraoperative conversion to conventional bypass. Postoperative angiography showed patency of graft without stenosis of the anastomosis in all 4 patients. The patients did not complain of significant pain and their postoperative hospital stay was 5 to 11 days. The lower mini-sternotomy approach or “xyphoid” approach proposed by Benetti seems to be an excellent novel approach giving the freedom of extension of the incision if needed with satisfactory exposure for left ITA harvest and access to LAD as well as the distal RCA, and causes less postoperative incisional pain.
　Jpn. J. Cardiovasc. Surg. 29: 21-24 (2000)

Successful Staged Repair of an Anomalous Origin of the Right Pulmonary Artery from the Ascending Aorta 　　T. Funatsu, et al.…25

Successful Staged Repair of an Anomalous Origin of the Right Pulmonary Artery from the Ascending Aorta

(Department of Cardiovascular Surgery and Department of Pediatric Cardiology＊, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan)

Toshihiro Funatsu Hidefumi Kishimoto Hiroaki Kawata

Takuya Miura Takayoshi Ueno Shigemitsu Iwai

Masamichi Ono Tomoko Kita＊ Toru Nakajima＊

Takeshi Nakada

We report a successful staged repair of anomalous origin of right pulmonary artery from the ascending aorta in a neonate. A two-day-old girl, who suffered from severe circulatory failure, was admitted. In spite of all medical treatment, acidosis and systemic hypotension developed. Right pulmonary artery banding was performed in an emergency procedure, resulting in immediate elevation of systemic blood pressure. Definitive operation was subsequently performed on the 48th day after birth. The right pulmonary artery, which was de-banded and divided from aorta, was anastomosed directly to the pulmonary trunk in a side-to-end manner. The postoperative course was uneventful and the pulmonary artery pressure was within the normal range.
　Jpn. J. Cardiovasc. Surg. 29: 25-28 (2000)

A Case of Intraoperative Acute Aortic Dissection during Mitral Valve Plasty 　　M. Ueno, et al.…29

A Case of Intraoperative Acute Aortic Dissection during Mitral Valve Plasty

(Second Department of Surgery, Faculty of Medicine, Kagoshima University, Kagoshima, Japan)

Masahiro Ueno Yukinori Moriyama Yoshifumi Iguro

Koichi Hisatomi Riichiro Toda Hitoshi Matsumoto

Akira Kobayashi Goichi Yotsumoto Yoshihiro Fukumoto

Akira Taira

A 74-year-old man undergone mitral valve plasty. After cessation of cardiopulmonary bypass, bleeding persisted from the cardioplegia injection site and dilatation of the ascending aorta with discoloration was observed. The diagnosis of type A aortic dissection extending to the descending aorta was made by transesophageal echocardiogram. Replacement of the ascending aorta was performed under deep hypothermic circulatory arrest. The postoperative course was uneventful. The false lumen of the aortic arch and descending aorta was thrombosed completely on postoperative computed tomography. Intraoperative aortic dissection is a rare but fatal complication of cardiopulmonary bypass. Prompt recognition and appropriate surgical management are of prime importance.
　Jpn. J. Cardiovasc. Surg. 29: 29-32 (2000)

A Case of Papillary Fibroelastoma of the Left Ventricular Septum Complicated with a Rheumatic Valve 　　M. Yoda, et al.…33

A Case of Papillary Fibroelastoma of the Left Ventricular Septum Complicated with a Rheumatic Valve

(Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan)

Masataka Yoda＊ Jun Hirota Satoshi Saito

Hideyuki Tomioka Hideyuki Uesugi Toru Okamura

Akira Murata Akihiko Kawai Mitsuhiro Hachida

Hitoshi Koyanagi

A 50-year-old man was referred to our hospital with a tumor in the left ventricle. He had suffered from rheumatic fever when 14 years old. He had shown signs of chronic heart failure due to atrial fibrillation and rheumatic valves (ASr, MSr) for 10 years. There was a history of unaccountable fever and rash, so infective endocarditis was suspected and echocardiography was performed. It showed a homogeneous mass with a diameter of approximately 10mm, fixed directly to the left ventricular septum 20mm below the aortic valvular ring. At operation, the tumor was excised together with endocardium and a part of the muscular coat. The rheumatic aortic and mitral valves were replaced with a 21mm SJM AHP and a 27mm SJM MTK mitral valve, respectively. Tricuspid annuloplasty (TAP) (De Vega 29mm) was also performed. Histopathological examination of the tumor revealed benign papillary fibroelastoma. It suggested that the tumors were secondary to mechanical wear and tear, and represent a degenerative process due to rheumatic valve disease.
　Jpn. J. Cardiovasc. Surg. 29: 33-36 (2000)

An Operated Case of Aortic Regurgitation due to Rheumatoid Arthritis 　　F. Kawazuma, et al.…37

An Operated Case of Aortic Regurgitation due to Rheumatoid Arthritis

(Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan)

Fumiaki Kawazuma Sinichi Ooki Yoshio Misawa

Katsuo Fuse

We encountered a rare case of aortic regurgitation due to rheumatoid arthritis. A 53-year-old man was admitted with severe heart failure due to aortic regurgitation. He had been treated for rheumatoid arthritis for 5 years with methotrexate. After treatment for heart failure, his aortic valve was successfully replaced with an Omnicarbon prosthetic valve. Histopathological examination of the excised aortic valve showed rheumatoid granuloma. His post-operative course was uneventful.
　Jpn. J. Cardiovasc. Surg. 29: 37-40 (2000)

An Operative Case of Right Coronary Artery Fistula Communicated to the Left Atrium 　　C. Kondo, et al.…41

An Operative Case of Right Coronary Artery Fistula Communicated to the Left Atrium

(Department of Cardiovascular Surgery, Hamamatsu Medical Center, Hamamatsu, Japan)

Chiaki Kondo Hitoshi Kusagawa Hiroshi Hata

We report a very rare case of a coronary artery fistula with communication between the right coronary artery and the left atrium. The patient was a 45 year-old woman admitted for evaluation of heart murmur. Selective coronary angiography demonstrated right coronary artery-left atrial fistula. The operation was indicated due to volume overload of the left ventricle. At operation, the proximal portion of the coronary fistula was successfully ligated from the epicardial side and the entrance of the fistula into the left atrium was directly closed from the inside of the left atrium under the cardiopulmonary bypass. The post-operative course was uneventful. Post-operative coronary angiography showed disappearance of the fistula. Angiography 6 months later, demonstrated that the orifice of the right coronary artery remained dilated, while the diameter of the distal site was normalized.
　Jpn. J. Cardiovasc. Surg. 29: 41-44 (2000)

A Case of Off-Pump Coronary Artery Bypass for Multivessel Disease Combined with Repair of Abdominal Aortic Aneurysm and Bilateral Common Iliac Artery Aneurysms 　　T. Kawata, et al.…45

A Case of Off-Pump Coronary Artery Bypass for Multivessel Disease Combined with Repair of Abdominal Aortic Aneurysm and Bilateral Common Iliac Artery Aneurysms (Department of Surgery III, Nara Medical University, Nara, Japan) Tetsuji Kawata Yoichi Kameda Nobuoki Tabayashi Takashi Ueda Michitaka Kimura Motoaki Yasukawa Shigeki Taniguchi A 76-year-old man with multivessel disease in the coronary artery and abdominal aortic aneurysm, including the bilateral common iliac artery aneurysms, underwent off-pump coronary artery bypass (OPCAB) combined with repair of the aneurysms. We were able to perform three coronary artery bypass graftings (left internal thoracic artery-left anterior descending artery, saphenous vein graft-diagonal branch, and saphenous vein graft-atrio-ventricular branch) using an Octopus 2 and a “Lima” suture technique without cardiopulmonary bypass. The postoperative course was uneventful. All grafts were patent on postoperative angiograms. OPCAB combined with repair of abdominal aortic aneurysm was useful for the high-risk patient. Jpn. J. Cardiovasc. Surg. 29: 45-48 (2000)

A Case of Video-Assisted Thoracoscopic Surgery for Clipping the Patent Ductus Arteriosus in a Child 　　M. Matsumoto, et al.…49

A Case of Video-Assisted Thoracoscopic Surgery for Clipping the Patent Ductus Arteriosus in a Child

(Department of Cardiovascular Surgery, Cardiovascular Center Sakakibara Hospital, Okayama, Japan)

Mitsuaki Matsumoto Takato Hata Kohki Nakamura

Yoshimasa Tsushima Sohei Hamanaka Hidenori Yoshitaka

Susumu Shinoura Hitoshi Minami Satoru Otani

We performed a video-assisted thoracoscopic surgery (VATS) to clip the patent ductus arteriosus (PDA), which was 5 mm in internal diameter, in an 11-year-old girl, who first underwent a coil embolization ending in failure. Under general anesthesia with one-lung ventilation in a right lateral decubitus position, four thoracostomies were made in the left hemithorax. The PDA was clipped by two titanium clips, the length of which is 11 mm at closing. Transesophageal echocardiography confirmed the location of the PDA and the absence of a residual shunt. The patient showed neither left recurrent laryngeal nerve dysfunction nor hemorrhage after operation, and was discharged on the 9th postoperative day. The clipping of the PDA by VATS can be applied for PDA without calcification if the external diameter is up to 7 mm. This technique was minimally invasive and reliable. It was excellent in terms of the high quality of life achieved by the patient.
　Jpn. J. Cardiovasc. Surg. 29: 49-52 (2000)

Two Cases of Aortic Root Replacement Using Anatomic Ventriculoaortic Junction Suture 　　S. Hayashi, et al.…53

Two Cases of Aortic Root Replacement Using Anatomic Ventriculoaortic Junction Suture

(Department of Cardiovascular Surgery, Chugoku Rosai Hospital, Cerebro-Cardiovascular Center, Kure, Japan)

Saihou Hayashi Jun Kawamoto

For aortic root replacement in annuloaortic ectasia (AAE), an artificial prosthesis is commonly sutured to the aortic annuls (hemodynamic ventriculoaortic junction). In this case report, suturing was conducted using the anatomic ventriculoaortic junction along with full-thickness-suturing. The first case was a 28-year-old man and the second, his 31-year-old brother. The former showed AAE (maximum diameter, 120mm) with 4° AR and the latter, AAE (maximum diameter, 54mm) without AR. The present method is simple due to the flat suture line and is quite reliable owing to full-thickness-suturing.
　Jpn. J. Cardiovasc. Surg. 29: 53-56 (2000)

Successful Surgical Treatment for an Aortic Arch Aneurysm Combined with an Aberrant Right Subclavian Artery 　　Y. Sudo, et al.…57

Successful Surgical Treatment for an Aortic Arch Aneurysm Combined with an Aberrant Right Subclavian Artery

(Department of Cardiovascular Surgery, Funabashi Municipal Medical Center, Chiba, Japan)

Yoshio Sudo Yoshiharu Takahara

An 81-year-old man complaining of back pain was admitted. Computed tomographic scan revealed an aortic arch aneurysm and an abnormal retroesophageal artery. It was believed to be an aberrant right subclavian artery. The diagnosis was confirmed by angiogram. Although there was no evidence of rupture, his back pain prompted us to perform emergency surgery. Through median sternotomy using a cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion, total arch replacement was done. There was evidence of impending rupture, which was probably the cause of his back pain. The proximal portion of the aberrant right subclavian artery was severely calcified, so the right subclavian artery was reconstructed. It was anastomosed with one branch of the arch graft which passed the anterior of the trachea. The postoperative course was uneventful. We believe median sternotomy was a proper approach for such a situation.
　Jpn. J. Cardiovasc. Surg. 29: 57-59 (2000)

A Case of Vein Graft Bypass for Superior Mesenteric Artery Stenosis 　　N. Kanemitsu, et al.…60

A Case of Vein Graft Bypass for Superior Mesenteric Artery Stenosis

(Department of Cardiovascular Surgery, Kochi Municipal Hospital, Kochi, Japan)

Naoki Kanemitsu Manabu Okabe Seiichiro Wariishi

Takasumi Nakamura

We report a case of successful saphenous vein bypass grafting for superior mesenteric artery stenosis. A 50-year-old man complained of abdominal pain which was not induced by either eating or defecation. He was admitted to our hospital and examinations of the gastrointestinal tract revealed no abnormality. Angiography showed stenosis of the superior mesenteric artery (SMA), but not of the celiac artery (CA) or inferior mesenteric artery (IMA). We speculated that his symptom was due to SMA stenosis and poor collateral circulations from the CA, IMA and internal iliac arteries. Saphenous vein bypass grafting for SMA was undertaken successfully and abdominal pain disappeared completely.
　Jpn. J. Cardiovasc. Surg. 29: 60-62 (2000)