|Usefulness of Percutaneous Phrenic Nerve Stimulation for Assessing Phrenic Nerve Injury after Pediatric Cardiac Surgery|
|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|
|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|
|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
Jpn. J. Cardiovasc. Surg. 29: 10-16 (2000)
|Surgical Treatment for Type IIIb Aortic Dissection in Association with a True Aortic Aneurysm|
|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|
|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
Jpn. J. Cardiovasc. Surg. 29: 21-24 (2000)
|Successful Staged Repair of an Anomalous Origin of the Right Pulmonary Artery from the Ascending Aorta|
|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|
|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
Jpn. J. Cardiovasc. Surg. 29: 29-32 (2000)
|A Case of Papillary Fibroelastoma of the Left Ventricular Septum Complicated with a Rheumatic Valve|
|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|
|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|
|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
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|
|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|
|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|
|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|
|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|
|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)