Japanese Journal of Cardiovascular Surgery Vol.29, No.3

Originals

Efficacy of Combined Antegrade and Retrograde Intermittent Cold Cardioplegia for Patients with Prolonged Aortic Cross-Clamping 　　M. Kamada, et al.…127

Efficacy of Combined Antegrade and Retrograde Intermittent Cold Cardioplegia for Patients with Prolonged Aortic Cross-Clamping

(Department of Thoracic and Cardiovascular Surgery, Tohoku University, Sendai, Japan)

Makoto Kamada Atushi Iguchi Motohisa Tofukuji

Hitoshi Yokoyama Hiroji Akimoto Mikio Ohmi

Koichi Tabayashi

We evaluated the efficacy of combined antegrade and retrograde intermittent cold cardioplegia for patients with prolonged aortic cross-clamping. Thirty patients with cross-clamping time of more than 4 h were divided into three groups according to the method of cardioplegia. Antegrade crystalloid cardioplegia was performed in 9 cases, combined antegrade and retrograde crystalloid cardioplegia was performed in 5 cases, and combined antegrade and retrograde cold blood cardioplegia was performed in 16 cases. There was no statistical difference in mean aortic cross-clamping time among the three groups. The hospital mortality was 33% in the antegrade crystalloid group, 20% in the combined crystalloid group, and 0% in the combined blood group. There was a significant statistical difference in the hospital mortality between the antegrade crystalloid and combined blood group. The incidence of low cardiac output syndrome (LOS) was 67% in the antegrade crystalloid group, 20% in the combined crystalloid group, and 6% in the combined blood group. There was a significant difference in the incidence of LOS between antegrade crystalloid and combined blood groups. The recovery rate of spontaneous rhythm after the release of the cross-clamp was also significantly greater in the combined blood group than in the antegrade crystalloid group. In conclusion, combined antegrade and retrograde intermittent cold cardioplegia provides excellent myocardial protection for patients with prolonged aortic cross-clamping.
　Jpn. J. Cardiovasc. Surg. 29: 127-133 (2000)

How Do Patients Think about Their Operation Scar after Cardiac Surgery? 　　Y. Kanaoka, et al.…134

How Do Patients Think about Their Operation Scar after Cardiac Surgery?

(Department of Cardiovascular Surgery, Iwakuni National Hospital, Iwakuni, Japan)

Yuji Kanaoka Kazuo Tanemoto Keiichiro Kuroki

Because of the improved safety of cardiovascular surgical techniques, the small incision approach, called minimally invasive cardiac surgery (MICS), has recently been employed. In some cases of MICS, however, prolonged extracorporeal circulation time is required, and it is not minimally invasive in some aspects. It has been reported that the most prominent advantages of MICS is reducing the adverse consequences of conventional full-sternotomy, such as pain, bleeding and risk of mediastinitis, therefore it is helpful to reduce the period of hospitalization and costs. The small incision and cosmetic advantage is one of the objective advantages of MICS, so we interviewed 139 patients who underwent cardiac surgeries, to find out how they think of their operation scar. Most (61.9%) of the patients were not bothered by their scar, and the presence of keloid lesions mattered move than the size of their wound. What the patients considered to be most important were less pain after operation and shorter hospital stay, not to mention good results of the operation. The size and place of the wound ranked low in importance. It is important to be aware of the difference in thinking between the operative wound by patients and by the healthy medical staff. Furthermore it is important to recognize the difference between minimaly invasiveness and small incisions in cardiac surgery.
　Jpn. J. Cardiovasc. Surg. 29: 134-138 (2000)

Stroke after Coronary Artery Bypass Grafting 　　K. Minakata, et al.…139

Stroke after Coronary Artery Bypass Grafting

(Department of Cardiovascular Surgery, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan)

Kenji Minakata, Yutaka Konishi Masahiko Matsumoto

Michihito Nonaka Narihisa Yamada

Risk factors for stroke after coronary artery bypass grafting (CABG) were assessed. We retrospectively investigated 681 consecutive patients who underwent isolated, first-time CABG at our institute between 1987 and 1998. Ninety-eight patients (14%) had a history of preoperative stroke. They tended to be older and with a higher incidence of peripheral vascular disease (PVD) than those without preoperative stroke. In spite of several techniques for prevention of postoperative stroke, such as the aortic non-touch technique, 14 patients (2.0%) suffered postoperative stroke. Postoperative stroke was diagnosed soon after surgery in 7 patients (50%), and the causes of stroke in these patients seemed to be intraoperative manipulation of the ascending aorta in 5, and hypoperfusion during cardiopulmonary bypass in two. Stroke in the remaining 7 patients occurred after normal awakening from anesthesia, and the cause was unknown. We then compared the patients with postoperative stroke (n=14) to those without postoperative stroke (n=667). Statistical analysis demonstrated no significant difference between the two groups in variables such as history of preoperative stroke, duration of cardiopulmonary bypass, and prevalence of PVD. Four (29%) of the patients with postoperative stroke died, due mainly to aspiration pneumonia. The morbidity and mortality of the patients who suffered postoperative stroke were very high.
　Jpn. J. Cardiovasc. Surg. 29: 139-143 (2000)

Surgical Treatment for Cardiac Myxomas: 20 Years' Experience in Consecutive 17 Cases 　　M. Yamamura, et al.…144

Surgical Treatment for Cardiac Myxomas: 20 Years' Experience in Consecutive 17 Cases

(Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan and Department of Cardiovascular Surgery, Osaka City Medical Center＊, Osaka, Japan)

Mitsuhiro Yamamura Takashi Miyamoto Katsuhiko Yamashita,

Hideki Yao Kazushige Inoue Hirokazu Minamimura＊

Torazo Wada Hiroe Tanaka Masaaki Ryomoto

Tomohiko Sugimoto

Between March 1976 and February 1996, 17 patients underwent surgical treatment for cardiac myxomas. There were 5 men and 12 women with a mean age of 55 years (range: 22 to 78 years). The location was the left atrium in 13, right atrium in 2, right ventricle in 1 and multiple locations in 1. Since 1978 the standard operative method to treat left atrial myxoma has been a biatrial approach with complete removal of cardiac myxoma and partial resection of the atrial septum. There were no perioperative deaths, but 1 patient had a permanent pace-maker implantation, 2 had transient atrial fibrillation during the early postoperative period, and 1 had acute pulmonary edema after resection of a right ventricular myxoma. There were two late deaths, not related to cardiac event and one recurrence with multiple myxomas. Overall with long term follow-up, the actual survival rate at 10 years was 75% (n=6), with a mean follow-up of 7.1 years, with a 100% follow-up ratio (17 patients). We conclude that the biatrial approach with complete removal of the left atrial myxomas and partial resection of the atrial septum is one of the best procedures for surgical treatment.
　Jpn. J. Cardiovasc. Surg. 29: 144-148 (2000)

Surgical Treatment of Carotid Occlusive Disease 　　I. Morita, et al.…149

Surgical Treatment of Carotid Occlusive Disease

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

Ichiro Morita Hiroshi Inada Hisao Masaki

Taiji Murakami Atsushi Tabuchi Yoshiaki Fukuhiro

Atsuhisa Ishida Daiki Kikugawa Kouichi Endo

Takashi Fujiwara

Twenty-two patients who underwent vascular reconstruction for carotid occlusive disease by April 1998 were examined in terms of long-term results. The cause of disease was atherosclerosis in 16, and aortitis in 6. The operation method included CEA in 11 and bypass in 5 cases in the atherosclerosis cases, and CEA in 2 and bypass in 6 cases in aortitis. Cases of occlusive disease included 1 early occlusion (atherosclerosis) and 4 late occlusion (atherosclerosis 2, aortitis 2). The cause of early occlusion was considered to be due to technical factors, but late occlusion was thought to be related to progression of disease, anastomotic intimal thickening, and recurrence of inflammation. It is important to enforce strict operative indications, accurate intraoperative monitoring, and perioperative drug control.
　Jpn. J. Cardiovasc. Surg. 29: 149-155 (2000)

Accuracy of Measurement of Cardiac Output and Circulating Blood Volume Levels by Pulse Dye Densitometry, and Postoperative Management of the Open Heart Surgery 　　Y. Hamada, et al.…156

Accuracy of Measurement of Cardiac Output and Circulating Blood Volume Levels by Pulse Dye Densitometry, and Postoperative Management of the Open Heart Surgery (Department of Surgery II, Ehime University School of Medicine, Ehime, Japan) Yoshihiro Hamada Tetsuya Yamamoto Tatsuhiro Nakata Yasuaki Kashu Yuji Watanabe Hiroyuki Kikkawa Kanji Kawachi Using the DDG-2001 pulse dye densitometer, cardiac output (CO) and circulating blood volume (BV) were determined before and after the operation, and its accuracy and the significance of postoperative management were studied. Referring to 14 cases undergoing open heart surgery, CO and BV were determined using the DDG-2001 before application of the cardiopulmonary bypass and immediately, 4h and 12h after the operation. The level of CO was compared with that determined by the thermodilution method, and the level of BV with that calculated from hemoglobin levels determined before and after the cardiopulmonary bypass application and the priming volume in the circuit. Further, body fluid balance after the operation was calculated, and its relation to BV was studied. As to the correlation coefficient and inclination of the regression line, they were 0.77 and 0.849 with CO, and 0.821 and 0.844 with BV, respectively. Upon completion of the operation BV decreased, but increased again 4h and 12h later, although the body fluid balance was negative. CO and BV determined by the pulse dye densitometry favorably correlated with those determined by other methods. Immediately after the operation BV decreased, but then increased in the course of time, although the body fluid balance was negative. Jpn. J. Cardiovasc. Surg. 29: 156-160 (2000)

Surgical Treatment of Arterial Aneurysm due to Salmonella Infection 　　Y. Hanafusa, et al.…161

Surgical Treatment of Arterial Aneurysm due to Salmonella Infection

(Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan)

Yuji Hanafusa Motomi Ando Yutaka Okita

Tetsuro Morota Kenji Minatoya Ritsu Matsukawa

Soichiro Kitamura

Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to Salmonella infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with Salmonella infection had bacteremia. The incidence of bacteremia in patients with Salmonella infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including in situ reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to Salmonella infection.
　Jpn. J. Cardiovasc. Surg. 29: 161-167 (2000)

Case Reports

A Successful Case of Concomitant Aortic Valve Replacement Using an Intravalvular Implantation Technique and Coronary Artery Bypass Grafting in Aortitis Syndrome 　　H. Matsushita, et al.…168

A Successful Case of Concomitant Aortic Valve Replacement Using an Intravalvular Implantation Technique and Coronary Artery Bypass Grafting in Aortitis Syndrome (First Department of Surgery, Kumamoto University School of Medicine, Kumamoto, Japan) Hiroo Matsushita Ryuji Kunitomo Junichi Utoh Masahiko Hara Nobuo Kitamura Aortitis syndrome is a disease of non-specific inflammation of the arterial wall which produces necrosis and fibrosis of the intima. Indications, timing, and the choice of operative procedures should be determined carefully because of its complex pathology. We encountered a patient with combined aortic valve incompetence and left main coronary artery stenosis due to aortitis syndrome. The patient received adequate steroid therapy and the inflammatory reaction was well controlled before surgery. The patient underwent concomitant aortic valve replacement using an intravalvular implantation technique and coronary artery bypass grafting. The hospital course of the patient was uneventful. Neither paravalvular leakage nor inflammatory recurrence was observed during 18 months of follow-up. Jpn. J. Cardiovasc. Surg. 29: 168-171 (2000)

A Case of Successful Treatment of Prosthetic Graft Infection Caused by Bacteroides fragilis 　　Y. Hanafusa, et al.…172

A Case of Successful Treatment of Prosthetic Graft Infection Caused by Bacteroides fragilis

(Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan)

Yuji Hanafusa Yutaka Okita Motomi Ando

Kenji Minatoya Osamu Tagusari Soichiro Kitamura

A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded Bacteroides fragilis. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by Bacteroides fragilis, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.
　Jpn. J. Cardiovasc. Surg. 29: 172-174 (2000)

Redo Coronary Artery Bypass Grafting via a Small Thoracotomy without Cardiopulmonary Bypass 　　T. Tanaka, et al.…175

Redo Coronary Artery Bypass Grafting via a Small Thoracotomy without Cardiopulmonary Bypass

(Department of Cardiovascular Surgery, National Toyohashi Higashi Hospital, Toyohashi, Japan)

Tsuneo Tanaka Yasuhide Okawa Masahiro Toyama

Masaki Hashimoto Narihiro Ishida Koji Matsumoto

We report two cases the first was a 74-year-old woman who had received coronary artery bypass grafting ［SVG-to-LAD, SVG-to-Cx, SVG-to-RCA, the left internal thoracic artery (LITA) was mobilized but was unsuitable for the graft］ two years previously. Postoperative angiography revealed graft occlusion. Since repeated catheter intervention was not successful, reoperation was performed. A MIDCAB procedure with radial artery graft and proximal anastomosis was performed on the left axillary artery. The operation was successful and there were no complications. Two weeks after the operation, the graft patency was confirmed and she was discharged. The second case was a 64-year-old man who received coronary artery grafting ［LITA-to-LAD, SVG-to-Cx and SVG-to-RCA). Two months after the operation, recurrent chest pain was caused by severe stenosis of the LITA anastomotic site. Percutaneous transluminal coronary angioplasty was performed but was unsuccessful. He received redo CABG in the same manner using the saphenous vein. The postoperative course was uneventful and he was discharged 6 days after the operation. This procedure is useful for the patients whose left internal thoracic artery has been used on a previous operation. Good early results were obtained in both patients.
　Jpn. J. Cardiovasc. Surg. 29: 175-178 (2000)

A Case of Abdominal Aortic Aneurysm with Multiple Complications Treated by Endovascular Stent-Graft 　　N. Koizumi, et al.…179

A Case of Abdominal Aortic Aneurysm with Multiple Complications Treated by Endovascular Stent-Graft

(Second Department of Surgery, Tokyo Medical University, Tokyo, Japan)

Nobusato Koizumi Satoshi Kawaguchi Shin Ishimaru

Yukio Obitsu Hiromitsu Tsuchida Mikio Ishikawa

A high-risk abdominal aortic aneurysm patient with multiple complications was treated by a transluminally placed endovascular stent-graft. A tapered stent-graft composed of 3 units of self-expandable Z stents covered with ultra-thin woven Dacron was inserted through an 18 Fr sheath via the femoral artery. The stent-graft was deployed successfully, and endovascular exclusion of the abdominal aortic aneurysm was achieved. The endoluminal stent-graft treatment is an option for minimally invasive operation in comparison with conventional open surgery, and appears to be effective for aortic aneurysms in certain selected cases.
　Jpn. J. Cardiovasc. Surg. 29: 179-182 (2000)

Surgical Treatment of Acute Occlusion of Persistent Sciatic Artery 　　H. Minami, et al.…183

Surgical Treatment of Acute Occlusion of Persistent Sciatic Artery

(Cardiovascular Surgery, Kobe Rosai Hospital, Kobe, Japan and Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji＊, Himeji, Japan)

Hiroya Minami Noboru Wakita Yujirou Kawanishi

Ikuro Kitano Tsutomu Shida＊

Persistent sciatic artery is an embryonic blood vessel that continues to feed the lower extremity after fulfilling an important role in lower limb development during early gestation. It is so rare that only 20 cases have been reported in Japan. This paper describes a case of acute occlusion of a persistent sciatic artey. A 78-year-old woman was admitted to hospital because of sudden onset of severe pain in her left leg. Angiography showed bilateral persistant sciatic arteries (complete type) with occlusion of the left artery and a small aneurysm on the right side. Left femoro-popliteal bypass was performed and postoperative angiography showed that the graft was patent.
　Jpn. J. Cardiovasc. Surg. 29: 183-186 (2000)

Axillo-Iliac Bypass in a Child with Relative Graft Stenosis Following Reconstructive Repair of Interrupted Aortic Arch Type A 　　S. Yamaguchi, et al.…187

Axillo-Iliac Bypass in a Child with Relative Graft Stenosis Following Reconstructive Repair of Interrupted Aortic Arch Type A

(Division of Cardiovascular Surgery, Chiba Cardiovascular Center, Ichihara, Japan)

Seiichi Yamaguchi Hirokazu Murayama Naoki Hayashida

Kozo Matsuo Atsushi Hata Soichi Asano

Hiroyuki Watanabe Yasutsugu Nakagawa Katsuhiko Tatsuno

A 12-year-old girl had relative graft stenosis following the reconstruction of type A interrupted aortic arch. At 25 days after birth she underwent ascending aorta-descending aorta bypass with a 7mm knitted Dacron graft, ligation of the patent ductus arteriosus and pulmonary artery banding. She had patch closure of a ventricular septal defect (VSD) as well at 20 months of age. At age 12 catheterization was carried out, because she had headache and dizziness on exertion. The pressure of the ascending aorta was 163/79mmHg and the pressure gradient between the ascending and the descending aorta was 65mmHg. Aortography revealed severe stenosis of the graft, which might have occurred according to her growth. An extra-anatomic bypass was placed between the right axillary and the right common iliac artery through the intrapleural and preperitoneal route with a 10mm Dacron graft. Six months later, the blood pressure was 108/63mmHg in the upper extremities, the pressure gradient between the upper and lower extremities was reduced to 18mmHg, and headache and dizziness had disappeared.
　Jpn. J. Cardiovasc. Surg. 29: 187-190 (2000)

A Case of Anastomotic Pseudoaneurysm at an Anastomosis between Two Woven Dacron Prostheses Following Aortic Arch Replacement 　　O. Izumiyama, et al.…191

A Case of Anastomotic Pseudoaneurysm at an Anastomosis between Two Woven Dacron Prostheses Following Aortic Arch Replacement

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

Osamu Izumiyama Akio Yamashita Satoru Sugimoto

Masahito Baba

The possibility of anastomotic pseudoaneurysms as a life-threatening complication following prosthetic graft replacement for an aneurysmal disease or an arterial occlusive disease is well known. However the pseudoaneurysm at an anastomosis between two prostheses is rarely reported. We present a successful surgical treatment for an anstomotic pseudoaneurysm between two prostheses. A 75-year-old man underwent total arch replacement for a true aortic arch aneurysm with the aid of selective cerebral perfusion five years previously. The graft used was a composite prosthesis consisting of 26 mm woven Dacron graft for the aortic arch to which a hand-made three-tributary graft was sutured for major three arch vessels. An anastomotic pseudoaneurysm at an anastomotic site between the 26 mm graft and a tributary graft was suspected on a chest CT and then differentially diagnosed by aortography. The anastomotic pseudoaneurysm was surgically resected and the anastomosis was repaired with 3-0 polypropylene continuous sutures with the aid of hypothermic circulatory arrest. Anastomotic aneurysm can occur only between a native vessel and a prosthesis but also between two prostheses. Therefore we should make periodical examinations such as CT after prosthetic graft replacement.
　Jpn. J. Cardiovasc. Surg. 29: 191-194 (2000)

A Case of Simultaneous Surgical Treatment for Descending Thoracic Aortic Aneurysm, Coronary Artery Disease and Left Common Iliac Artery Stenosis under Partial Cardiopulmonary Bypass 　　K. Inoue, et al.…195

A Case of Simultaneous Surgical Treatment for Descending Thoracic Aortic Aneurysm, Coronary Artery Disease and Left Common Iliac Artery Stenosis under Partial Cardiopulmonary Bypass (Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, Hyogo, Japan) Kazushige Inoue Takashi Miyamoto Toshihiko Saga Katuhiko Yamashita Hideki Yao Torazou Wada Masaaki Ryomoto A 72-year-old woman underwent simultaneous combined surgical treatment for descending aortic aneurysm, coronary artery disease and left common iliac artery stenoses. The operation was performed through the left posterolateral thoracotomy via the 6th intercostal space and a left retroperitoneal approach. At first, 10mm woven Dacron graft was anastomosed to the abdominal aorta as an inlet of the cardiopulmonary bypass and the left femoral vein was used for venous drainage. A saphenous vein graft was anastomosed to the left anterior descending artery during partial cardiopulmonary bypass with the heart beating. Secondly, the aneurysm was replaced with 24mm woven Dacron graft. Thirdly, the proximal end of the vein graft was anastomosed to the Dacron graft of the descending aorta. Finally after cardiopulmonary bypass was terminated, the distal end of the woven Dacron graft for arterial perfusion was anastomosed to the left external iliac artery in end-to-side fashion. The postoperative course was uneventful. We conclude that simultaneous operation for descending aortic aneurysm and coronary artery bypass grafting through left thoracotomy with the heart beating is useful in these combined diseases. Jpn. J. Cardiovasc. Surg. 29: 195-198 (2000)