Japanese Journal of Cardiovascular Surgery Vol.29, No.6

Originals

  • Role of Neutrophils in Pulmonary Dysfunction during Cardiopulmonary Bypass 　　H. Gohra, et al.……363
    Role of Neutrophils in Pulmonary Dysfunction during Cardiopulmonary Bypass
    Hidenori Gohra Tomoe Katoh Toshiro Kobayashi
    Masahiko Nishida Ken Hirata Akihito Mikamo
    Haruhiko Okada Kimikazu Hamano Nobuya Zempo
    Kensuke Esato

    (First Department of Surgery,Yamaguchi University School of Medicine, Ube, Japan)
    To test the hypothesis that neutrophils play a role in lung injury during cardiopulmonary bypass, granulocyte elastase and myeloperoxidase release from pulmonary circulation were measured, as well as the respiratory index, before and after cardiopulmonary bypass. The production of granulocyte elastase and myeloperoxidase in the pulmonary circulation, and the respiratory index also elevated significantly after cadiopulmonary bypass. Furthermore, the level of granulocyte elastase and myeloperoxidase released from pulmonary circulation correlated with the changes of the repiratory index and preoperative pulmonary artery pressure.These data indicate that neutrophils play a major role in pulmonary dysfunction occurring after cardiopulmonary bypass, which is accentuated in patients with pulmonary hypertension.
    　 Jpn. J. Cardiovasc. Surg. 29:363-367(2000)
  • Forearm Problems after CABG Using Radial Artery Grafts 　　K. Nakamura, et al.……368
    Forearm Problems after CABG Using Radial Artery Grafts
    Koki Nakamura Takato Hata Yoshimasa Tsushima
    Mitsuaki Matsumoto Sohei Hamanaka Hidenori Yoshitaka
    Makoto Mohri Genta Chikazawa Susumu Shinoura
    Kazushi Minami Satoru Otani

    (Department of Cardiovascular Surgery, Sakakibara Hospital Cardiac Center, Okayama, Japan)
    There have been many reports radial artery grafts (RA) are useful in CABG, but there were very few reports about hand grasping power (GP), edema and sensory disturbance after surgery. From January to April, 1999, RA were used for 14 patients (R group) and were not in 16 patients (C group) among a total of 30 coronary artery bypass grafting procedures. The patients in the two groups were statistically similar. RA were anastomosed to #12 in 9 patients and #14 in 5. GP and the circumference of forearms were examined and sensory disturbance was also checked preoperarively and at 1, 2 and 4 weeks postoperatively. In both groups, left GP decreased slightly after surgery but gradually recovered. Four weeks after surgery, it was 26.2±9.6 kg in the R group and 26.2±7.5 kg in the C group (NS). the difference between left and right circumference of forearms, which indicates the degree of edema, was significantly larger in the R group than in the C group (3.5±3.6 mm vs. -0.5±3.8 mm, 1 week postoperatively, P<0.05). However, it gradually improved in the R group (2.1±2.6 mm at 2 weeks and 1.9±2.6 mm at 4 weeks postoperatively ). No sensory disturbance was seen at any time. Therefore we conclude that using RA in CABG is not only useful but is also safe and does not increase postoperative risk.
    　Jpn. J. Cardiovasc. Surg. 29: 368-372 (2000)
  • Twelve-year Experience with the Carpentier-Edwards Pericardial Aortic Valve in Patients Over 60 Years Old 　　H. Nakajima……373
    Twelve-year Experience with the Carpentier-Edwards Pericardial Aortic Valve in Patients Over 60 Years Old
    Hiroyuki Nakajima* Michel Marchand

    (Department of Cardiac Surgery, Trousseau Hospital and Francois Rabelais University, Tours, France and Mitsubishi Kyoto Hospital*, Kyoto, Japan)
    Background and aims of the study: Mechanical valves repuire anticoagulation therapy, and bioprostheses may need reoperation due to structural valvular deterioraton (SVD). In older patients, the rate of SVD seems to be lower than in younger patients. The aim of this study was to evaluate a 12-year clinical experience of the Carpentier-Edwards pericardial bioprosthesis in the aortic position in patients over 60 years of age. Methods: A total of 652 patients over 60 years old (453 men, 199 women; mean age 72.2±6.7 years) underwent isolated aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis in our institution between july 1984 and December 1995. The main indication for valve replacement was idiopathic calcific stenosis in 476 cases (75%), while dystrophic insufficiency was present in 124 of the cases (19%). Other conditions were rheumatic, congenital, prosthetic valve dysfunction and endocarditis. All patients, except one, were followed up for an average of 4.36 years after surgery resulting in a total follow up period of 2,802 patient-years (pt-yr). Results: The operative mortality rate was 3.1% (20/652) including 138 late deaths. Thirty patients died of valve-related causes (14 sudden deaths, 11 thromboembolisms, 3 prosthetic valve endocarditises (PVE) and 2 bleeding events). Twelve years after surgery, the actuarial rate of freedom from valve-related death was 76±24%. Valve-related complications included 37 thromboembolic episodes (1.4%/pt-yr), 9 bleeding events (0.4%/pt-yr), 14 PVEs (0.4%/pt-yr), 2 structural valve failures (0.07%/pt-yr) and 8 reoperations (0.3%/pr-yr). Twelve years after surgery, freedom from thromboembolism was 80±12%, freedom from bleeding events was 96±3%, freedom from PVE was 96±2%, freedom from structural valve failures was 98±2% and freedom from reoperation was 96±4%. Conclusion: With a low rate of structural valve failure 12 years after surery and a good clinical perfofmance, the Capentire-Edwards pericardial bioprosthesis is a reliable alternative for patients over 60 years of age.
    　Jpn. J. Cardiovasc. Surg. 29: 373-377 (2000)

Case Reports

  • A Case of Rheumatic Tricuspid Stenosis 22 Years after Initial Mitral Valve Replacement 　　Y. Kato, et al.……378
    A Case of Rheumatic Tricuspid Stenosis 22 Years after Initial Mitral Valve Replacement
    Yasuyuki Kato Fumitaka Isobe Sakashi Noji
    Yasuyuki Sasaki Kojiro Kodera Takumi Ishikawa
    Yoshiei Shimamura Hiroshi Kumano Keima Nagamachi
    Masahiro Daimon

    (Department of Cardiovascular Surgey, Osaka National Hospital, Osaka, Japan)
    Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenodis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with sever leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure grandient of 6 mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.
    　Jpn. J. Cardiovasc. Surg. 29: 378-381 (2000)
  • Postoperative Aortic Regurgitation Probably due to Use of Gelatin-Resorcin-Formalin Glue for Acute Aortic Dissection 　　H. Kin, et al.……382
    Postoperative Aortic Regurgitation Probably due to Use of Gelatin-Resorcin-Formalin Glue for Acute Aortic Dissection
    Hajime Kin* Tadashi Okubo Yoshiyuki Kamigaki
    Noriyasu Kawada

    (Department of Cardiovascular Surgry, Nakadori General Hospital, Akita, Japan and Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center*, Iwate, Japan)
    A 45-year-old man presented with cough and dyspnea. He had undergone reconstruction of the ascending aorta for acute aortic dissection (DeBakey type I) 5 months previously, at which time we used the gelatin-resorcin-formalin glue (GRF glue) for reconstruction of the wall layer. Preoperative transesophageal echocardiography and aortography revealed aortic regurgitation due to redissenction of the aortic root. Intraoperatively, dehiscence was noted between the right coronary sinus including the coronary ostia and the non-coronary sinus. These intraoperative findings suggested that the pathology leading to the redissection was related to the previous use of GRF glue. The redissected segment appeared to be necrotic on macroscopic examination intraoperatively, however histological examination revealed only degenerative changes, and there was no evidence of the glue. He was treated by the modified Bentall method and had a good postoperative course after discharge. In this case, it is also conceivable that tissue necrosis resulted from the use of too much formalin.
    　Jpn. J. Cardiovasc. Surg. 29: 382-385(2000)
  • Rupture of the Thoracic Aortic Aneurysm in the Course of Corticostreroid Therapy for Rheumatic Interstitial Pneumonitis 　　Y. Yoshida, et al.……386
    Rupture of the Thoracic Aortic Aneurysm in the Course of Corticosteroid Therapy for Pheumatic Interstitial Pneumonitis
    Yasushi Yoshida Kazunori Uemura Junichi Utoh
    Nobuo Kitamura

    (First Department of Surgery, School of Medicine, Kumamoto University, Kumamoto, Japan)
    Pheumatoid arthritis and interstitial pneumonitis were diagnosed in a 72-year-old man and thoracic computed tomography revealed an aortic arch aneurysm 50 mm in diameter. Steroid therapy gave symptomatic relief and improved labotatory findings, but hyperglycemia and hypertension developed. Two months later the thoracic aneurysm ruptured, and computed tomography revealed expansion of the aneurysm to 60 mm in diameter and surrounding hematoma. Emergency total arch replacement was performed successfully with deep hypothermic cardiopulmonary bypass and selective cerebral perfusion. The steroid therapy was considered to be responsible for the rapid expansion and rupture of the thoracic aneurysm. When prescribing steroids for a patient who has a concomitant atherosclerotic cardiovascular disease, we should not only control the steroidal side effects strictly, but also carefully watch the course of the atherosclerotic lesion.
    　Jpn.J. Cardiovasc. Surg. 29: 386-388(2000)
  • A Case of Successful Transcatheter Arterial Embolization of Ruptured Celiac Artery Aneurysm 　　T. Misumi, et al.……389
    A Case of Successful Transcatheter Arterial Embolization of Ruptured Celiac Artery Aneurysm
    Takahiko Misumi Kumi Nishikawa Mikito Yasudo
    Yasuyuki Yamada Hiroya Kumamaru

    (Department of Cardiovascular Surgery, Ashikaga Red Cross Hospital, Ashikaga, Japan)
    Celiac artery aneurysm is very uncommon. We report an even more rare case in which a life threatening ruptured aneurysm was treated successfully by an emergency interventional procedure. A 72-year-old man was transferred to our hospital with a chief complaint of severe epigastralgia. In the emergency room, the patient was already in shock and emergeny CT scan suggested severe intraperitoneal bleeding. The diagnosis of ruptured celiac artery aneurysm was confirmed by subsequent angiographic examinations and immediate hemostasis was successfully achieved by transcatheter arterial embolization. One year after the embolization, the patient remains asymptomatic and follow-up CT scans revealed reduction in size and thrombotic occlusion of the aneurysm.
    　Jpn. J. Cardiovasc. Surg. 29: 389-392(2000)
  • Implantation Technique of a Left Ventricular Assist System through a Small Right Parasternal Incision 　　T. Tanala, et al.……393
    Implantation Technique of a Left Ventricular Assist System through a Small Right Parasternal Incision
    Tsuneo Tanaka Yasuhide Okawa Masahiro Toyama
    Masaki Hashimoto Narihiro Ishida Koji Matsumoto

    (Department of Cardiovascular Surgey, Toyohashi National Higashi Hospital, Toyohashi, Japan)
    A 62-year-old man was transferred to our institution with ventricular fibrillation. Percutaneous cardiopulmonary support (PCPS) was established and he underwent successful percutaneous transluminal coronary angioplasty. Since his left ventricular function did not recover, he was placed on a left ventricular assist system (LVAS). Under general anesthesia, a 10-cm longitudinal incision was made on the right parasternum. The third and fourth cartilages were completely resected. The pericardium was incised longitudinally. At first, an inflow cannula was insected to the right side of the left artium. The ascending aorta was then partially excluded and an outflow cannula with a 10 mm Gore-Tex prosthesis was anastomosed end-to-side to the aorta with a continuous Gore-Tex suture. After the pump was establieshed, PCPS was gradually discontinued. During 9 days of support, his left ventricular function recovered and subsequently he was weaned from LVAS. Unfortunately, he died two days after LVAS removal. We think this procedure is useful because it is easy to perform, reduces the bleeding, shortens the operating time.
    　Jpn. J. Cardiovasc. Surg. 29: 393-395 (2000)
  • Two-Staged Operation for Multiple Aortic Aneurysm 　　E. Suenaga, et al.……396
    Two-Staged Operation for Multiple Aortic Aneurysm
    Etsuro Suenaga Hisao Suda Yuji Katayama
    Manabu Sato Noriko Yamada Tsuyoshi Itoh*

    (Department of Cardiovascular Surgery, Nagasaki Kouseikai Hospital, Nagasaki, Japan and Department of Thoracic and Cardiovascular Surgery, Saga Medical School*, Saga, Japan)
    A 69-year-old man was admitted for treatment of thoracic aneurysm. DSA revealed multiple aortic aneurysms: three true aneurysms which were located at the distal arch, the thoracoabdominal aorta at the diaphragm level and the infrarenal abdominal aorta, 60 mm, 55 mm and 55 mm in diameter, respectively and two pseudo-aneurysms which were located in the abdominal aorta just below the right renal artery and the right common iliac artery. We decided to perform a two-staged operation. Before the first operation, 1,200 ml of autologous blood was stored for perioperative blood transfusion. Initially, total arch replacement was performed using deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. One month after the first operation, total thoraco-abdominal aorta replacement was performed by a retroperitoneal approach with mild hypothermia. The Th 9, 10 and 11 intercostal arteries were reconstructed. Distal anastomosis was performed at both common iliac arteries. Blood transfusion was not reqired for blood pooling and reduction of primig volume in the cardiopulmonary bypass system.
    　Jpn. J. Cardiovasc. Surg. 29: 396-399 (2000)
  • A Case of Aortic Valve Replacement in Patient with Chronic Idiopathic Thrombocytopenic Purpura 　　H. Hirose, et al.……400
    A Case of Aortic Valve Replacement in Patient with Chronic Idiopathic Thrombocytopenic Purpura
    Hiroyuki Hirose Motomi Shiono
    Yukihiko Orime Shinya Yagi
    Tomonori Yamamoto Haruhiko Okumura
    Mitsumasa Hata Hanao Negishi
    Yukiyasu Sezai Yoshihiro Matsukawa*

    (The Second Department of Surgery, and The First Department of Medicine*, Nihon University School of Medicine, Tokyo, Japan)
    A 66-year-old woman with aortic stenosis and idiopathic thrombocytopenic purpura (ITP) underwent concomitant splenectomy and aortic valve replacement (AVR). High-dose transvenous gamma-globulin therapy (400 mg/kg/day) was performed for five days before surgery. The number of platelet, which was 6.0×104/mm3 on admission slighty increased to 7.0×104mm3 before surgery. The aortic valve was replaced by an ATS 19 mm prosthesis using cardiopulmonary bypass. Platelets were transfused postoperatively. Perioperative hemorrhage was moderate, and the postoperative course was uneventful. This was the second case we treated by concomitant cardiac surgery and splenectomy. It was safely performed after high-dose transvenous gamma-globulin therapy.
    　Jpn. J. Cardiovasc.Surg. 29: 400-403(2000)
  • A Case of Surgical Treatment of Stanford Type A Closing Aortic Dissection with Variable Morphological Changes 　　T. Shimomura, et al.……404
    A Case fo Surgical Treatment of Stanford Type A Closing Aortic Dissection with Variable Morphological Changes
    Takeru Shimomura Tsuyoshi Yuasa Akihiko Usui
    Takashi Watanabe Kenzo Yasuura

    (Department of Thoracic and Cardiovascular Surgery, Nagoya University School of Medicine, Nagoya, Japan)
    A 62-year-old woman presented with acute chest pain. An enchanced CT scan showed type A closing aortic dissection. An ulcer-like projection (ULP) was observed in the abdominal aorta above the superior mesenteric artery on aortography. At 3 months after onset, recurrent chest pain appeared. An enchanced CT scan showed a false lumen in the ascending aorta and a new ULP and localized false lumen were opacified in the distal ascending aorta on aortography. The graft replacement of the ascending aorta was performed using open distal anastomosis under circulatory arrest and retrograde cerebral perfusion. Two intimal tears were found in the aortic root and distal ascending aorta. The patient recovered without complications. Postoperative CT scan and aortography revealed no residual false lumen.
    　Jpn. J. Cardiovasc. Surg. 29: 404-406(2000)
  • A Case of Reoperation for a Starr-Edwards Ball Valve Prosthesis Implanted in the Aortic Position 29 Years Previously 　　Y. Sugawara, et al.……407
    A Case of Reoperation for a Starr-Edwards Ball Valve Prosthesis Implanted in the Aortic Position 29 Years Previously
    Yuji Sugawara Taijiro Sueda Kazumasa Orihashi
    Masanobu Watari Kenji Okada Osamu Ishii
    Yuichiro Matsuura

    (First Department of Surgery, Hiroshima University, School of Medicine, Hiroshima, Japan)
    A 53-year-old woman had dyspnea on effort since half a year previously and was categorized as NYHA II. She had suffered from chronic atrial fibrillation (AF) for three years. She had undergone aortic valve replacement using a Starr-Edwards ball valve (SEV) for aortic regurgitation and mitral commissurotomy for mitral stenosis 29 years previously. Echocardiography revealed mitral stenosis with an orifice area of 0.9 cm2 and neither dysfunction of the SEV nor abnormal findings on the valve itself. She underwent mitral valve replacement and left atrial maze procedure for AF. Because of the intraoperative findings of the cloth wear-covered SEV cage, redo aortic valve replacement was performed simultaneously. St. jude Medical valves were used for valve prostheses. There was no complication and the ECG returned to sinus rhythm postoperatively. These has been no report of a patient with such a long period between SEV implantation and replacement in Japan. This experience made us realize again the importance of attention to the cloth wear covered cage during long term follow up for SEV.
    　Jpn. J. Cardiovasc. Surg. 29: 407-409（2000)
  • Emergency Aortic Root Remodeling for Rupture of a Large Ascending Aortic Aneurysm 　　E. Suenaga, et al.……410
    Emergency Aortic Root Remodeling for Rupture of a Large Ascending Aortic Aneurysm
    Etsuro Suenaga Hisao Suda Tsuyoshi Itoh*

    (Department of Cardiovascular Surgery, Nagasaki Kouseikai Hospital, Nagasaki, Japan and Department of Thoracic and Cardiovascular Surgery, Saga Medical School*, Saga, Japan)
    Aortic valve preservation is indicated in cases of aortic regurgitation caused by sinotubular junction (STJ) dilatation with ascending aortic aneurysm. We performed aortic remodeling using a tailored Dacron graft for the rupture of a large ascending aortic aneurysm. The patient was a 68-year-old woman. She was admitted in shock with cardiac tamponade. Chest CT showed a large ascending aortic aneurysm, 11 cm in maximum diameter. Echocardiography demonstrated moderate cardiac effusion and massive aortic regurgitation. The ascending aorta was dilated from the STJ to the innominate artery, but the aortic valve appeared normal. We decided to preserve the native aortic valve. We performed aortic root remodeling using a 26 mm Dacron graft (Yacoub's procedure). An intraoperative endoscopic study revealed the disappearance of aortic regurgitation (AR). The coronary arteries were reconstructed by the Carrel patch technique. Postoperative aortography revealed trivial AR, and the patient was discharged two weeks after the operation. We conclude that this technique avoids the complications associated with mechanical valve implantation and necessary lifetime anticoagulation.
    　Jpn. J. Cardiovasc. Surg. 29: 410-413 (2000)
  • Mechanical Valve Stuck in the Mitral Position in a Patient with Antiphospholipid Syndrome 　　H. Takakura, et al.……414
    Mechanical Valve Stuck in the Mitral Position in a Patient with Antiphospholipid Syndrome
    Hiromitsu Takakura Tatsuumi Sasaki Kazuhiro Hashimoto
    Takashi Hachiya Katsuhisa Onoguchi Motohiro Oshiumi
    Shigeryuki Takeuchi

    (Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center, Saitama, Japan)
    A 69-year-old woman, who had undergone mitral valve replacement, developed acute congestive heart failure and was transferred to our institution. Cineradiography demonstrated that two leaflets of the St. Jude Medical valve were stuck in a closed position. Emergency redo mitral valve replacement was performed with a CarboMedics valve. Postoperative hematological studies yielded a diagnosis of antiphospholipid syndrome. Although postoperative anticoagulant therapy was performed more carefully than usual, the prosthesis became stuck again. Therefore, a third operation was performed using a tissue prosthesis. We concluded that mitral valve plasty should be a first option for patients with antiphospholipid sysdrome undergoing mitral valve surgery. Should prosthetic valve replacement be required, a tissue prothesis world be best.
    　Jpn. J. Cardiovasc. Surg. 29: 414-417(2000)
  • A Case of Inflammatory Pseudoaneurysm of the Ascending Aorta 　　R. Takahashi, et al.……418
    A Case of Inflammatory Pseudoaneurysm of the Ascending Aorta
    Ryuichi Takahashi Issei Kiso Atsu Mori
    Yoshito Inoue

    (Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan)
    A 74-year-old man had an inflammatory pseudoaneurysm of the ascending aorta. He was admitted to a local hospital because of loss of appetite. Following intravenous hyperalimentation, he was placed under ventilatory support because of acute respiratory failure. Since his high fever and respiratory failure continued, he was transferred to our hospital. Computed tomography revealed a sealed rupture of an aneurysm in the ascending aorta. During the operation, we identified the ascending aortic aneurysm but it was very tightly attached to the surrounding wall in the perianeurysmal space. To avoid excessive hemorrhage, we closed the communication between the aneurysm and the aorta with a Dacron graft patch under deep hypothermia with circulatory arrest. He was discharged 42 days after operation without any complications. A pathological evaluation of the aneurysmal wall revealed an inflammatory pseudoaneurysm with a thick and inflammatory infiltration in the adventitia.
    　Jpn. J. Cardiovasc. Surg. 29: 418-421 (2000)