Japanese Journal of Cardiovascular Surgery Vol.30, No.1

Originals

  • The Effects of Rewarming Speed on Cerebral Circulation and Oxygen Metabolism during the Rewarming Period of Cardiopulmonary Bypass 　　T. Honda, et al.…1
    The Effects of Rewarming Speed on Cerebral Circulation and Oxygen Metabolism during the Rewarming Period of Cardiopulmonary Bypass

    (Second Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan and Osaka Medical Center and Research Institute for Maternal and Child Health*, Izumi, Japan)
    Tasuku Honda Satoshi Kamihira Shingo Ishiguro
    Hiroaki Kuroda Shigetsugu Ohgi Tohru Mori*
    We investigated the effects of rewarming speed on cerebral circulation and oxygen metabolism during cardiopulmonary bypass (CPB). Twenty-four adult patients who had undergone open heart surgery with moderately hypothermic CPB were divided into two groups. In the slow rewarming group (group S), the rates of increase of blood temperature were under 0.1ºC/min. In the rapid rewarming group (group R), they were more than 0.1ºC/min. Mean blood flow velocity in the middle cerebral artery (mean MCAv) was measured by transcranial Doppler ultrasonography, and the index of cerebral oxygen consumption was evaluated by Doppler-estimated cerebral metabolic rate for oxygen (D-CMRO2). The change of oxyhemoglobin level in the brain (Oxy Hb) was monitored by near-infrared spectroscopy. In group S, mean MCAv and D-CMRO2 changed in a parallel manner following the changes of the rectal temperature throughout the periods, and mean MCAv was always higher than D-CMRO2. In group R, however, the rate of increase of D-CMRO2 was more rapid than that in group S from the beginning of rewarming, and D-CMRO2 exceeded the level of mean MCAv just before termination of CPB. In addition, Oxy Hb in group R showed more rapid changes than that of group S. In conclusion, rapid rewarming during CPB may cause the disruption of cerebral flow-metabolism coupling.
    Jpn. J. Cardiovasc. Surg. 30: 1-6 (2001)
  • The Extended Retroperitoneal Approach for Treatment of Abdominal Aortic Aneurysms 　　I. Kigawa, et al.…7
    The Extended Retroperitoneal Approach for Treatment of Abdominal Aortic Aneurysms

    (Division of Cardiovascular Surgery, Department of Surgery, Mitsui Memorial Hospital, Tokyo, Japan)
    Ikutaro Kigawa Sachito Fukuda Yoichi Yamashita
    Yasuhiko Wanibuchi
    From July 1984 to June 1998, 159 patients with infrarenal abdominal aortic aneurysms (AAA) were surgically treated in our hospital by the extended retroperitoneal (ERP) approach described by Williams et al. There were 132 men and 27 women, with a mean age of 69.3 years. Of the 159 patients, 82 (52%) had hypertension, 62 (39%) had coronary artery disease, of which 20 cases had previously received coronary artery bypass grafting, 17 (11%) had diabetes, 16 (10%) had thoracic aortic disease, 15 (9.4%) had cerebrovascular disease, and 14 (8.8%) had chronic renal dysfunction, including 6 cases on hemodialysis. Among these patients treated with this approach, 67 cases underwent tube grafting and 92 received Y-grafting. Patent inferior mesenteric arteries were ligated in all cases except one. Postoperative morbidity was observed in 54 cases (34%); lower extremity ischemia including microembolism or acute graft occlusion in 13, abdominal complication including paralytic ileus, liver dysfunction, or gastrointestinal hemorrhage in 11, wound complication in 9, pulmonary in 7, cardiac in 6, cerebral in 4, and the others in 4. No patient suffered ischemic colitis. There was hospital mortality in 4 cases (2.5%). Two patients died because of myonephropathic metabolic syndrome on second postoperative day. Two patients with combinations of several co-existing diseases died because of respiratory failure or multi-organ failure on the 48th and 141st postoperative day. Oral feeding was restarted at a mean of 2.7 days after the operation, and 64% of the cases did not require blood products. The mean postoperative hospital stay of survivors was 16.9 days (range, 7-63 days). Based on our clinical experience, we believe that the ERP approach is a safe and useful procedure for elective surgery for AAA to enable fast recovery and short hospital stay, especially in older and high-risk patients.
    　Jpn. J. Cardiovasc. Surg. 30: 7-10 (2001)
  • Quadruple, Quintuple and Sextuple Bypass with Exclusive Use of In Situ Arterial Conduits in Coronary Artery Bypass Grafting 　　T. Ishida, et al.…11
    Quadruple, Quintuple and Sextuple Bypass with Exclusive Use of In Situ Arterial Conduits in Coronary Artery Bypass Grafting

    (Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan)
    Toru Ishida Hiroshi Nishida Yasuko Tomizawa
    Sakashi Noji Hideyuki Tomioka Atsushi Morishita
    Masahiro Endo Hitoshi Koyanagi
    Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999,62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomosis of GEA was rather poorer than that of proximal (p＝0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.
    　Jpn. J. Cardiovasc. Surg. 30: 11-14（2001)
  • Cardiac Surgery for Takayasu's Disease 　　Y. Isomatsu, et al.…15
    Cardiac Surgery for Takayasu's Disease

    (Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan)
    Yukihisa Isomatsu Hiroyuki Tsukui Shuichi Hoshino
    Yasushi Nishiya
    Eight patients with Takayasu's disease underwent cardiac surgery between 1983 and 1998. All were women and the age at the time of operation ranged from 42 to 68 years (mean, 53.8 years). They were divided into two groups according to the coronary artery involvement: group A (n＝3) had aortic regurgitation with an intact coronary artery and underwent aortic valve replacement (AVR); group B (n＝5) had coronary artery lesion and underwent coronary artery bypass grafting (CABG) concomitant with or without AVR. All AVR procedures were performed using mechanical valves. At the CABG operation, saphenous veins alone were used in three cases and the left internal thoracic artery and saphenous veins in two. The actuarial survival rate was 65.6% at 5 years and 32.8% at 10 years. There were no early or late deaths in group A. On the contrary, there were one hospital death and two late deaths in group B. We discussed the timing of surgical intervention, the kind of prosthetic valve, the material of bypass graft and the procedure of CABG, the postoperative steroid use, and the surgical prognosis. The optimal timing of surgery for cardiac involvement is, needless to say, the inactive phase of inflammation. However, there are some patients who require operations during the active phase because of medically intractable or worsening symptoms. There is a consensus regarding the kind of prosthesis, and the mechanical valve is usually employed. There are still controversies regarding the material of grafts. We do not know the late results of saphenous vein graft in Takayasu's disease although saphenous vein is thought to be the choice of graft and several CABG procedures are advocated. The left internal thoracic artery might be used as a graft if the patient with Takayasu's disease had no subclavian artery lesions and was stable with an antiinflammatory regimen. We recommend the postoperative steroid therapy to control inflammation and also describe the antiinflammatory regimen after cardiac surgery in Takayasu's disease. It is essential that we have to meticulously follow up the patients with Takayasu's disease who underwent cardiac operations, paying especial attention to the side effects of steroid as well as the progression of inflammation.
    　Jpn. J. Cardiovasc. Surg. 30: 15-18 (2001)
  • Reoperation for Aortic St. Jude Medical Valves in Six Cases 　　T. Shichijo, et al.…19
    Reoperation for Aortic St. Jude Medical Valves in Six Cases

    (Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan)
    Takeshi Shichijo Osamu Oba Keizou Yunoki
    Masahiro Inoue
    From 1982 to March 1999, 276 St. Jude Medical prostheses were implanted in aortic position. Of the 276 patients, 6(2.2%) required redo aortic valve replacement due to aortic stenosis. The peak velocity measured by continuous-wave Doppler echocardiography ranged from 3.5 to 5.4m/sec with mean of 4.55m/sec. Aortic stenosis was attributable to pannus formation in 3 patients, valve thrombosis in 1 patient, and prosthesis-patient mismatch in 2 patients. The prostheses of patients with pannus formation were implanted in valve orientation parallel to the septum. It is therefore considered that the St. Jude Medical prosthesis should be implanted perpendicular to the septum in the aortic position and that careful follow-up observation of the patients should be made, particularly with echocardiography.
    　Jpn. J. Cardiovasc. Surg. 30: 19-22 (2001)

Case Reports

  • A Case of Combined Operation for Aortic Regurgitation with Low Cardiac Function and Arteriosclerosis Obliterans 　　N. Konagai, et al.…23
    A Case of Combined Operation for Aortic Regurgitation with Low Cardiac Function and Arteriosclerosis Obliterans

    (Department of Cardiovascular Surgery, Hachioji Medical Center of Tokyo Medical University and Second Department of Surgery, Tokyo Medical University*, Tokyo, Japan)
    Naoki Konagai Mitsunori Maeda Hiromi Yano
    Tatsuhiko Kudo Shin Ishimaru*
    Coronary artery disease is common in patients with abdominal aortic aneurysm and arteriosclerosis obliterans, and one-stage or two-stage coronary artery bypass grafting have been performed. However, few operative cases of concomitant heart valve disease and arteriosclerotic disease have been reported. This case presented with severe aortic valve regurgitation (LVEF24.3%) and arteriosclerosis obliterans (ASO) of both iliac arteries. To maintain the IABP catheter route and to prevent lower limb ischemia, aortic valve replacement with a bileaflet mechanical valve and abdominal aortic replacement with a bifurcated graft were carried out simultaneously. In spite of the high degree of operative invasiveness with median sternotomy and abdominal incision, the postoperative course was uneventful due to the shortened operation time and maintenance of good peripheral circulation.
    　Jpn. J. Cardiovasc. Surg. 30: 23-25 (2001)
  • A Case of Quadricuspid Aortic Valve Associated with Single Coronary Ostium 　　H. Takakura, et al.…26
    A Case of Quadricuspid Aortic Valve Associated with Single Coronary Ostium

    (Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center, Saitama, Japan)
    Hiromitsu Takakura Tatsuumi Sasaki Kazuhiro Hashimoto
    Takashi Hachiya Katsuhisa Onoguchi Motohiro Oshiumi
    Shigeyuki Takeuchi
    A 63-year-old man developed acute congestive heart failure with orthopnea and was transferred to our institution. Aortography and transesophageal echocardiography demonstrated that the aortic valve was congenitally quadricuspid. In preoperative coronary angiography, the left anterior descending artery and the circumflex artery arose from the same orifice of the right coronary artery. So far as we know, quadricuspid aortic valve associated with a single coronary ostium is an extremely rare congenital cardiac anomaly combination. During aortic valve replacement for this particular case, antegrade cardioplegia including a selective coronary perfusion was considered unreliable, thus continuous retrograde blood cardioplegia was employed for intraoperative myocardial protection.
    　Jpn. J. Cardiovasc. Surg. 30: 26-28 (2001)
  • Two Successful Surgical Treatment for Primary Aortoenteric Fistula 　　M. Inoue, et al.…29
    Two Successful Surgical Treatment for Primary Aortoenteric Fistula

    (Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan)
    Masahiro Inoue Osamu Oba Takeshi Shichijyo
    Mikizo Nakai Sadahiko Arai Keiji Yunoki
    Noriyuki Tokunaga
    Between January 1991 and December 1998, we performed two successful procedures to repair abdominal aortic aneurysm with primary aortoenteric fistula. We had 197 surgical repair proceduers of aortic aneurysm during the same period. Incidence of primary aortoenteric fistula in abdominal aortic aneurysm was 1% in our institute. We performed primary closure of the fistula and removal of the possibily infected aneurysmal wall followed by anatomical grafting. We utilized omental wrapping for prophylaxis of potential graft infection. We achieved excellent surgical results in both patients by this approach.
    　Jpn. J. Cardiovasc. Surg. 30: 29-32 (2001)
  • Operation for Acute Aortic Dissection 13 Years after Operation for Funnel Chest in Marfan Syndrome 　　Y. Kanaoka, et al.…33
    Operation for Acute Aortic Dissection 13 Years after Operation for Funnel Chest in Marfan Syndrome

    (Department of Cardiovascular Surgery, Iwakuni National Hospital, Iwakuni, Japan and Department of Cardiovascular Surgery, Tsuyama Central Hospital*, Tsuyama, Japan)
    Yuji Kanaoka* Kazuo Tanemoto Takashi Murakami
    Keiichiro Kuroki Hitoshi Minami Masahiko Kuinose
    Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.
    　Jpn. J. Cardiovasc. Surg. 30: 33-35 (2001)
  • A Case of Intravenous Leiomyomatosis Extending into the Right Ventricle through the Internal Iliac Vein and Inferior Vena Cava 　　T. Ohto, et al.…36
    A Case of Intravenous Leiomyomatosis Extending into the Right Ventricle through the Internal Iliac Vein and Inferior Vena Cava

    (First Department of Surgery, Chiba University School of Medicine, Chiba, Japan)
    Toshiaki Ohto Masahisa Masuda Naoki Hayashida
    Yoko Pearce Mitsuru Nakaya Hideo Ukita
    Hitoshi Shimura Kenji Mogi Yoshihisa Tsukagoshi
    Nobuyuki Nakajima
    Intravenous leiomyomatosis (IVL) is defined as the extension into the venous channels of histologically benign smooth muscle tumors originating either from a uterine myoma or from the walls of a uterine vessel. We report a case of IVL extending to the right atrium and right ventricle through the right internal iliac vein and the inferior vena cava. The patient was a 43-year-old woman. The tumor was extirpated by simultaneous median sternotomy and laparotomy with the use of cardiopulmonary bypass. It was necessary to use cardiopulmonary bypass in order to open the right atrium. However, it proved difficult to insert the venous cannulae into the inferior vena cava due to the presence of the tumors. In order to perform the cannulation, a trans-right atrial excision of this tumor was necessary. Nevertheless, hemodynamic deterioration tended to occur during the procedure because of unexpected bleeding. We believe that to safely carry out this operation, it would be better to ensure circulatory arrest before trans-right atrial excision of the tumor. We have been continuing preventive anti-estrogen therapy because recurrence would be very likely if any tumorous tissue remained after surgery. Fortunately, no intravenous infiltration of the tumor has been detected by either pelvic computed tomography or ultrasonography during the 26-month follow-up period. Surgical excision of the tumors and postoperative medication are now believed to have been effective.
    　Jpn. J. Cardiovasc. Surg. 30: 36-39（2001)
  • A Case of Ischemic Cardiomyopathy Complicated by Porcelain Aorta Treated with Dor Operation and CABG Using an Occlusion Balloon 　　Y. Ko, et al.…40
    A Case of Ischemic Cardiomyopathy Complicated by Porcelain Aorta Treated with Dor Operation and CABG Using an Occlusion Balloon

    (Department of Cardiovascular Surgery, Kashiwa Hospital, Tokyo Jikei University School of Medicine, Kashiwa, Japan)
    Yoshihiro Ko Shigeki Horikoshi Asatoshi Mizuno
    Isao Aoki Shingo Taguchi
    In patients with so-called porcelain aorta characterized by calcification of the total aorta, manipulation of the ascending aorta can cause cerebral infarction and other conditions due to aortic dissection or rupture and calcified debris. In the present case with ischemic cardiomyopathy and porcelain aorta, an occlusion balloon catheter was inserted into the ascending aorta to avoid its clamping, followed by Dor operation and CABG under cardiac arrest with normothermic extracorporeal circulation. Techniques such as deep hypothermic circulatory arrest and surgery while the heart is beating are often currently used as auxiliary methods to avoid aortic clamp. However, the present case with insufficient left ventricular function required a left ventriculotomy, and thus the technique presented here is useful for shortening the surgical time and ensuring a reliable outcome of the operation.
    　Jpn. J. Cardiovasc. Surg. 30: 40-43 (2001)
  • A Case of Endoventricular Circular Patch Plasty for Postinfarction Akinetic Aneurysm of Left Ventricle, Associated with Severe Pulmonary Hypertension and Sustained Ventricular Tachycardia 　　M. Oshiumi, et al.…44
    A Case of Endoventricular Circular Patch Plasty for Postinfarction Akinetic Aneurysm of Left Ventricle, Associated with Severe Pulmonary Hypertension and Sustained Ventricular Tachycardia

    (Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center, Saitama, Japan and Department of Cardiovascular Surgery, Kawasaki City Hospital*, Kawasaki, Japan)
    Motohiro Oshiumi Kazuhiro Hashimoto Tatsuumi Sasaki
    Takashi Hachiya Katsuhisa Onoguchi Hiromitsu Takakura
    Shigeyuki Takeuchi Kiyokazu Kokaji*
    Endoventricular circular patch plasty was performed in a 42-year-old man, with a postinfarction akinetic aneurysm. The case was complicated with severe congestive heart failure, marked pulmonary hypertension (70% of systemic pressure) and sustained ventricular tachycardia. Cardiac catheterization data revealed low ejection fraction (20%), high pulmonary capillary wedge pressure (33mmHg) and high pulmonary arterial pressure (70/33mmHg), associated with enlarged end diastolic volume index (142ml/m2). After the operation, contractile and volumetric improvements were observed, however the severe pulmonary hypertension remained without any improvement. Disappearance of life-threatening arrhythmia allowed his discharge from the hospital, but unsatisfactory hemodynamic data, except for improved ejection fraction to 49%, turned our attention to patient selection and alternative treatment (cardiac transplantation) for such a severe case.
    　Jpn. J. Cardiovasc. Surg. 30: 44-47 (2001)
  • A Case of Double Valve Annuloplasty for Combined Valvular Disease with Protein-Losing Gastroenteropathy after Closure of VSD 　　J. Hasegawa, et al.…48
    A Case of Double Valve Annuloplasty for Combined Valvular Disease with Protein-Losing Gastroenteropathy after Closure of VSD

    (Division of Thoracic and Cardiovascular Surgery, Osaka Koseinenkin Hospital, Osaka, Japan)
    Junichi Hasegawa Keishi Kadoba Shigeo Nagasaka
    A 37-year-old man with protein-losing gastroenteropathy underwent surgery for mitral and tricuspid regurgitation. Serum protein level and serum albumin level were normalized after surgery. Gastrointestinal scintigraphy images using 99mTc-labeled albumin also showed no collection of tracer in gastrointestinal tract.
    　Jpn. J. Cardiovasc. Surg. 30: 48-50 (2001)
  • Three Cases of Chronic Type A Aortic Dissection with Connective Tissue Disease 　　Y. Ko, et al.…51
    Three Cases of Chronic Type A Aortic Dissection with Connective Tissue Disease

    (Department of Cardiovascular Surgery, Nakadori General Hospital, Akita, Japan and Department of Cardiovascular Surgery, Jikei University School of Medicine*, Tokyo, Japan)
    Yoshihiro Ko* Tadashi Okubo Ryouhei Hoshino
    Yoshiyuki Kamigaki
    We performed a modified Bentall operation and aortic arch replacement simultaneously in three cases of chronic type A aortic dissection with connective tissue disease. Two of the subjects were men. Ages ranged from 37 to 48 years. There were two cases of Marfan's syndrome, and one case of cystic medial necrosis. All patients had annuloaortic ectasia (AAE), severe aortic regurgitation (AR)and marked dilatation at the base and arch of the aorta with extensive dissecting lesions. Widespread, progressive vascular lesions are often seen, especially among cases of dissecting aneurysm of the aorta with connective tissue disease, and there is a high probability that new vascular lesions and valvular diseases will result after surgery. Therefore, cases must be followed, keeping in mind the possibility of early extended aortic operation and secondary surgery.
    　Jpn. J. Cardiovasc. Surg. 30: 51-54 (2001)
  • Successful Treatment of Cluster-Like Aneurysm Associated with Coarctation of the Aorta 　　A. Mizuno, et al.…55
    Successful Treatment of Cluster-Like Aneurysm Associated with Coarctation of the Aorta

    (Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan)
    Asatoshi Mizuno Hiromi Kurosawa Katsushi Koyanagi
    Isao Aoki
    A 19-year-old woman with thoracic aortic aneurysm complicating coarctation of the aorta was treated successfully. Aortography and 3D-CT showed the thoracic aortic aneurysm resembling a cluster of grapes. Coarctation of the aorta was seen between the aortic aneurysm and the descending aorta, and there was a 40mmHg pressure gradient between the ascending aorta and the descending aorta. At operation, the wall of the cluster-shaped saccular aortic aneurysm was very thin. We could see the blood flow through the wall, and we thought this patient was at high risk of ruptured aneurysm. The aneurysm was excised and replaced by a Hemashield tube graft, 16mm in diameter. The left subclavian artery was also constructed using a Hemashield tube graft, 8mm in diameter. Ruptured aneurysm in a patient with aortic aneurysm complicated by coarctation of the aorta has a high risk of death, so surgical intervention should be performed as soon as possible.
    　Jpn. J. Cardiovasc. Surg. 30: 55-57 (2001)