Japanese Journal of Cardiovascular Surgery Vol.30, No.3

Originals

Prognosis of Simultaneous Aortic Valve Replacement and Coronary Artery Bypass Grafting 　　S. Fukuda, et al.…111

Prognosis of Simultaneous Aortic Valve Replacement and Coronary Artery Bypass Grafting

(Division of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan)

Sachito Fukuda Akinobu Sasaki Youichi Yamashita

Ikutarou Kigawa Yasuhiko Wanibuchi

With increasingly elderly patients and also increasing numbers of patients with ischemic heart disease, the number of cases requiring coronary artery bypass grafting (CABG) combined with aortic valve surgery has recently been steadily increasing. In addition, the management of asymptomatic aortic valve diseases at the time of CABG still remains controversial. The purpose of this study was to evaluate the early and late prognoses of patients undergoing a simultaneous aortic valve replacement (AVR) and CABG. Between January 1988 and December 1997，17 patients underwent AVR and CABG. According to the pressure gradient, the patients were divided into four groups: five with aortic regurgitation (AR), two with mild aortic stenosis (AS), six with moderate AS and four with severe AS. The mean number of distal coronary anastomoses was 1.8 and a mechanical prosthesis was used in all cases. Hospital death occurred in one case with severe AS. The postoperative complications consisted of one mild AS case with transient complete atrio-ventricular block, two cases with a new cerebral infarction, one case with loss of consciousness, one moderate AS case with perioperative myocardial infarction, and one each of severe AS with, respectively, multiple organ failure, congestive heart failure (CHF) and acute renal failure. In addition, three valve-related complications were also observed. Late death occurred in two cases: one due to a cerebrovascular accident and one due to CHF. Both the early and late outcomes of the patients undergoing the above described simultaneous operation were satisfactory, suggesting that this combined operation is therefore considered to be an effective surgical modality for the treatment of ischemic heart disease patients.
　Jpn. J. Cardiovasc. Surg. 30: 111-114(2001)

Appropriate Protamine Administration to Neutralize Heparin after Cardiopulmonary Bypass Using the Hepcon®/HMS 　　N. Matsuyama, et al.…115

Appropriate Protamine Administration to Neutralize Heparin after Cardiopulmonary Bypass Using the Hepcon®/HMS

(Department of Thoracic Surgery, Hirakata City Hospital, Hirakata, Japan and Department of Thoracic and Cardiovascular Surgery, Osaka Medical College*, Takatsuki, Japan)

Nanritsu Matsuyama Kunio Asada* Keiichiro Kondo*

Toshihiro Kodama Shigeto Hasegawa* Yoshihide Sawada*

Atsushi Yuda* Masayoshi Nishimoto* Shinjiro Sasaki*

We reevaluated our heparin and protamine administration protocol during and after cardiopulmonary bypass (CPB). In 12 patients who underwent cardiac surgery using a heparin-coated circuit under mild hypothermia, heparin concentration was measured with the Hepcon®/HMS. Before initiating CPB, 1.5mg/kg of heparin was given to maintain the activated clotting time (ACT) at more than 400 sec. Patients were divided into two groups. In group I (n＝6), heparin was neutralized with an empirical dose of protamine (1.5mg protamine/mg initial heparin). In group II (n＝6), the protamine dose was determined by the residual heparin concentration, measured with the Hepcon®. Patients in group II received a lower dosage of protamine than group I (1.7±0.0 vs. 3.6±0.4mg/kg, p＜0.001). There were no significant differences in the intraoperative bleeding, postoperative bleeding and activated clotting time between the groups. By determining the appropriate protamine dosage, this heparin analysis system may be useful in managing CPB.
　Jpn. J. Cardiovasc. Surg. 30: 115-117(2001)

Management of Ruptured Isolated Aneurysms of the Iliac Artery 　　M.Tobe, et al.…118

Management of Ruptured Isolated Aneurysms of the Iliac Artery

(Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan and First Department of Surgery, Yokohama City University School of Medicine*, Yokohama, Japan)

Michio Tobe Jiro Kondo Kiyotaka Imoto

Shinichi Suzuki Susumu Isoda Naoki Hashiyama

Yoshimi Yano* Yoshinori Takanashi*

Fourteen patients with 22 solitary aneurysms of the iliac artery were operated in a 16-year period (1983 to 1999). Patients were divided into two groups. The non-ruptured group consisted of 6 patients who underwent surgical intervention before aneurysm rupture, and their mean age was 78.5 years. The ruptured group consisted of 8 patients who underwent surgical intervention for aneurysm rupture, with a mean age of 68.5 years. Although seven patients underwent emergency surgery for aneurysm rupture, less than half of them were operated upon within 24 hr after the onset of aneurysm rupture. The average size of aneurysms was similar in the two groups (common iliac artery aneurysms: non-ruptured 47 mm vs. ruptured 44mm in diameter, internal iliac artery aneurysms: non-ruptured 55mm vs. ruptured 55mm). Two patients died in the ruptured group, in which the operative mortality rate was 25%. Six patients (75%) of the ruptured group had hypovolemic shock, and two of them died during surgical repair. Of the patients with shock, two patients had intestinal ischemia after operation. Intestinal ischemia was one of the serious complications of ruptured iliac aneurysms. These results suggest that in patients with shock from ruptured iliac artery aneurysms, strategy for treatment is an important determinant of the outcome.
　Jpn. J. Cardiovasc. Surg. 30: 118-121(2001)

Pulmonary Vein Isolation for Chronic Atrial Fibrillation Associated with Mitral Valve Disease 　　H.Tanaka, et al.…122

Pulmonary Vein Isolation for Chronic Atrial Fibrillation Associated with Mitral Valve Disease

(Department of Thoracic Cardiovascular Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan and First Department of Surgery, Showa University*, Tokyo, Japan)

Hiroyuki Tanaka Kazuhiro Suzuki Takashi Narisawa

Takashi Suzuki Toshihiro Takaba*

Pulmonary vein isolation procedure was performed for atrial fibrillation associated with mitral valve disease in twelve patients. This simple procedure consisted of only isolation of the four pulmonary veins. Combined mitral valve surgery consisted of mitral valve plasty, mitral valve replacement with or without aortic valve replacement and tricuspid annuloplasty. Ten patients returned to a sinus rhythm. Two patients required DDD pacemaker implant for sick sinus syndrome. Left atrial contraction was detected in eight cases by trans-esophageal echography. Compared with the maze procedure, this operation was less invasive and preserved atrial appendage, helping to maintain normal secretion of atrial natriuretic peptide. This study suggests that the pulmonary vein isolation procedure may be an effective and simple maneuver for atrial fibrillation associated with mitral valvular disease.
　Jpn. J. Cardiovasc. Surg. 30: 122-125(2001)

Quality of Life of the Patients with Tetralogy of Fallot Corrected under Simple Deep Hypothermia More than 20 Years Ago 　　Y.Shiina,et al.…126

Quality of Life of the Patients with Tetralogy of Fallot Corrected under Simple Deep Hypothermia More than 20 Years Ago

(Third Department of Surgery and Department of Pediatrics*, Iwate Medical University, Morioka, Japan)

Yoshitaka Shiina Kazuaki Ishihara Kouhei Kawazoe

Katsuhiro Niitu Koutarou Oyama*

From October, 1960, to December, 1976, a total of 167 patients with the tetralogy of Fallot (TOF) underwent corrective repair under simple deep hypothermia at Iwate Medical University. In 59 out of 167 patients the address or telephone number were identified. Fifty-four patients, consisting of 25 males and 29 females, were investigated by written questionnaire or telephone interview. They were followed for 20-35 years. The mean (±SD) age at operation was 5.3±4.2 years old (range 6 months to 19 years). Reoperations were successfully performed on two patients with residual shunts. Among these, 43 patients (80%) were in NYHA class I, and 11 patients (20%) were class II. None of the patients were in class III or IV. Medication was not prescribed except in one patient. Twenty-eight patients (52%) married and gave birth to 34 children, none of whom had congenital heart disease. A total of 51 (94%) patients were employed, or were housewives. In conclusion, most patients were considered to have a good quality of life long after repair of TOF under simple deep hypothermia.
　Jpn. J. Cardiovasc. Surg. 30: 126-128 (2001)

The Outcome of One-stage Operation of Coronary Artery Bypass Grafting and Abdominal Aortic Aneurysm Repair 　　K.HyunIL,etal.…129

The Outcome of One-stage Operation of Coronary Artery Bypass Grafting and Abdominal Aortic Aneurysm Repair

(Department of Cardiovascular Surgery, Kumamoto Central Hospital, Kumamoto, Japan and Second Department of Surgery, Faculty of Medicine, Kagoshima University*, Kagoshima, Japan)

Kim Hyun IL Ryuzo Sakata* Takaaki Koshiji

Yoshihiro Nakayama Masashi Ura Yoshio Arai

Yuji Morishima Hideyuki Fumoto

Sixteen patients of mean age 68.4 years (range 55-83) underwent one-stage coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair at our institution between January 1998 and September 1999. The mean number of diseased coronary arteries was 2.4 as revealed by selective coronary arteriography and the location of the aneurysms, which consisted of 14 infrarenal types and one juxtarenal type. On CT scans, the size of the aneurysms ranged from 4.3-9.0cm with a mean diameter of 5.7cm. Routinely CABG was performed first under standard techniques using cardiopulmonary bypass. After the patient was weaned from the cardiopulmonary bypass and judged hemodynamically stable, the AAA repair was performed with heparin reversed but the chest wall remained open. An average of 2.9 coronary bypass grafts were performed, including mean 1.8 arterial grafts used. With respect to the AAA repair, one straight and fifteen bifurcated grafts were implanted, and one left renal artery was simultaneously reconstructed. There were neither operative and hospital deaths and any serious postoperative complications. Our detailed preoperative assessment suggests that, under cautious perioperative management, the one-stage operation of CABG and AAA repair is both effective and practical in carefully selected patients, who do not have extremely poor renal dysfunction, left ventricular dysfunction and respiratory dysfunction.
　Jpn. J. Cardiovasc. Surg. 30: 129-133 (2001)

Case Reports

The Waffle Procedure for Postoperative Constrictive Epicarditis after Expanded　Polytetrafluoroethylene Surgical Membrane as a Pericardial Substitute 　　H. Yao, et al.…134

The Waffle Procedure for Postoperative Constrictive Epicarditis after Expanded Polytetrafluoroethylene Surgical Membrane as a Pericardial Substitute

(Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan)

Hideki Yao Takashi Miyamoto Katsuhiko Yamashita

Sukemasa Mukai Torazou Wada Mitsuhiro Yamamura

Takashi Nakagawa Masaaki Ryomoto

Several substitutes have been utilized for pericardial closure after open heart surgery. A 55-year-old man was admitted to our hospital with a diagnosis of constrictive pericarditis 13 years after open mitral commissurotomy. At reoperation, the thickened pericardium was peeled off and the epicardium was covered with 0.1mm expanded polytetrafluoroethylene surgical membrane (Gore-tex®, sheet thickness 0.1mm). At the 7th postoperative day, he complained of fatigue and dyspnea. Physical examination revealed jugular venous distension, hepatomegaly, ascites and peripheral edema. Cardiac catheterization suggested the suspicion of pericardial or epicardial constriction. On the 3rd-operation, the Gore-tex® sheet was removed and multiple longitudinal and transverse incisions were made in the thickened epicardium, that is the waffle procedure, while protecting the myocardium and the coronary arteries. Perioperative hemodynamics improved remarkably. His cardiac index increased from 3.0 to 4.5l/min/m². The postoperative course was uneventful.
　Jpn. J. Cardiovasc. Surg. 30：134-136 (2001)

Pseudoaneurysm of the Ascending Aorta after Cardiovascular Surgery 　　T. Kugai and M. Chibana…137

Pseudoaneurysm of the Ascending Aorta after Cardiovascular Surgery

(Department of Cardiovascular Surgery, Okinawa Prefectural Naha General Hospital, Okinawa, Japan)

Tadao Kugai Mikio Chibana

Pseudoaneurysm of the ascending aorta is a rare but potentially fatal complication of cardiovascular surgery. Two cases are described in which a pseudoaneurysm of the ascending aorta developed and caused profuse intermittent bleeding through the MRSA infection of the sternotomy wound. One was a 29-year-old man who had undergone a mitral valve replacement five months previously. The aneurysm was successfully repaired with a prosthetic graft patch under deep hypothermia and circulatory arrest, when a bloodless field was obtained using a handmade double-balloon catheter. The other patient was a 79-year-old man who had undergone a graft replacement of the distal aortic arch four months previously. The possibility of surgical correction was also considered but was thought to carry too high a risk. Embolization of the aneurysm was therefore regarded as the only realistic alternative, but failed, and he died due to aneurysmal rupture. The importance of the diagnosis process and surgical and intervascular treatment of pseudoaneurysm of the ascending aneurysm is described.
　Jpn. J. Cardiovasc. Surg. 30: 137-139 (2001)

Primary Cardiac Leiomyosarcoma Originating from the Right Atrium 　　T. Suzuki, et al.…140

Primary Cardiac Leiomyosarcoma Originating from the Right Atrium

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

Takao Suzuki Morito Kato Shinichi Oki

Yasuhiro Tezuka Hiroaki Konishi Tsutomu Saito

Osamu Kamisawa Yoshio Misawa Katsuo Fuse

Primary malignant cardiac tumors are extremely rare. Among these, leiomyosarcoma are particularly exceptional and only about 20 surgically treated cases have been extensively described. We describe a case of right atrial leiomyosarcoma which was accidentally found by computed tomography. The tumor was surgically resected under extracorporeal circulation. Two months later the patient had cerebral hemorrhage due to a brain metastasis, which almost completely disappeared after irradiation. There was no other evidence of recurrence for 12 months after operation.
　Jpn. J. Cardiovasc. Surg. 30: 140-142 (2001)

A Case Report of Papillary Fibroelastoma of the Aortic Valve 　　H. Suzuki, et al.…143

A Case Report of Papillary Fibroelastoma of the Aortic Valve

(The Department of Cardiovascular Surgery, Mie General Medical Center, Yokkaichi, Japan)

Hitoshi Suzuki Yoshihiko Katayama Tetsuo Mizutani

A 51-year-old woman was referred to our hospital for investigation of an abnormal ECG. Transesophageal echocardiogram revealed a round mass which originated from the right coronary cusp of the aortic valve. The tumor was successfully excised from the aortic valve, and the postoperative echocardiogram showed normal aortic valve function. Pathological examination demonstrated papillary fibroelastoma.
　Jpn. J. Cardiovasc. Surg. 30: 143-145 (2001)

A Case of Ruptured Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia 　　M. Sakaguchi, et al.…146

A Case of Ruptured Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia

(Department of Cardiovascular Surgery, Nagano Red Cross Hospital, Nagano, Japan)

Masayuki Sakaguchi Naobumi Fujii Kazunori Nishimura

Nobuyuki Yanagiya

A 72-year-old woman complaining of lumbago was transferred to our hospital in a state of shock. An admission abdominal CT scan showed infrarenal aortic aneurysm reaching 8cm in maximal diameter and hematoma of the retroperitoneal space. A clinical diagnosis of ruptured abdominal aortic aneurysm was rapidly established. An emergency operation was performed under general anesthesia. Laparotomy disclosed an infrarenal abdominal aortic aneurysm and hematoma. The aorta was clamped just below the bilateral renal arteries. Straight graft replacement was performed. There was enough heparinization during the surgical procedure. Postoperative findings involved paraplegia and hypoesthesia from dermatome Th10 with associated urinary and fecal incontinence. The patient was discharged from our hospital. Spinal cord ischemia is a rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms. Presence of intra- and postoperative episodes of hypotension and the duration of the crossclamping seem to have been the most important factors for spinal cord ischemia in this case.
　Jpn. J. Cardiovasc. Surg. 30: 146-148 (2001)

Surgical Treatment for Active Infective Endocarditis with Sinus of Valsalva and Right Atrium Fistula 　　M. Takiguchi, et al.…149

Surgical Treatment for Active Infective Endocarditis with Sinus of Valsalva and Right Atrium Fistula

(Department of Cardiovascular Surgery, Matsudo City Hospital, Chiba, Japan)

Makoto Takiguchi Hiroshi Watanabe Masao Shibairi

Kazuro Utsumi Yuzo Nagase Hideo Ukita

We report here a surgical case of sinus of Valsalva and right atrium fistula associated with acute infective endocarditis (AIE) without perivalvular abscess cavity or aneurysm of the sinus of Valsalva (ASV). A 51-year-old man, who had been given a diagnosis of rheumatic aortic stenosis and regurgitation (AsR) and mitral stenosis and regurgitation (MsR) and tricuspid regurgitation (TR) by echocardiography, had a high fever 2 months after removal of teeth and AIE was diagnosed. He was referred to our hospital because sinus of Valsalva and right atrium fistula were detected by echocardiography and congestive heart failure (CHF) deteriorated during medical treatment. Perivalvular abscess cavity and ASV were not detected by preoperative echocardiography. Medical treatment was continued after admission, and operation was done after amelioration of the CHF and infection were recognized. The aortic valve was removed together with vegetation, two areas of the aortic wall in which the tissue was fragile were cauterized by electrocautery, patch closure at the sinus of Valsalva was performed using a partial of e-PTFE graft and aortic valve replacement (AVR) and mitral valve replacement (MVR) were done. Though residual aortic-right atrium shunt was detected after the operation, the postoperative course was good with no CHF or signs of infection.
　Jpn. J. Cardiovasc. Surg. 30: 149-151 (2001)

Emergency Surgical Management of Infective Endocarditis in Two Pregnant Cases 　　S. Hasegawa, et al.…152

Emergency Surgical Management of Infective Endocarditis in Two Pregnant Cases

(Department of Thoracic Surgery, Osaka Medical College, Osaka, Japan)

Shigeto Hasegawa Kunio Asada Junko Okamoto

Yukiya Nomura Yoshihide Sawada Keiichiro Kondo

Shinjiro Sasaki

We report two emergency mitral valve replacements performed successfully on 16-week and 29-week pregnant women for infective endocarditis in the active phase. The first patient was in severe acute heart failure on admission, and the fetus was already dead. Induced abortion was performed uneventfully 6 days after mitral valve replacement. The second patient presented with several episodes of systemic embolization. An echocardiography revealed giant movable vegetation on the mitral valve. The patient had emergency mitral valve replacement just after the Caesarian section. Both the patient and her baby weighting 1,374g had an uneventful good courses with no complication. We concluded that in emergency operations in pregnancy, saving the mother's life should have priority over all else, but we should find the way to rescue the fetus life if at all possible. Therefore, depending on the situation, we should not hesitate about doing a simultaneous operation, Caesarian section and heart surgery, for that purpose.
　Jpn. J. Cardiovasc. Surg. 30: 152-156 (2001)

A Case of Thoracoabdominal Aortic Aneurysm, Renovascular Hypertension with Ipsilateral Kidney Associated with Takayasu's Disease 　　Y. Hanafusa, et al.…157

A Case of Thoracoabdominal Aortic Aneurysm, Renovascular Hypertension with Ipsilateral Kidney Associated with Takayasu's Disease

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

Yuji Hanafusa Yutaka Okita Motomi Ando

Osamu Tagusari Kenji Minatoya Ritsu Matsukawa

Soichiro Kitamura

A 71-year-old woman who had Takayasu's disease underwent Y-grafting, bypass grafting between the abdominal aorta and left renal artery with 8mm ePTFE graft and right nephrectomy for infrarenal abdominal aortic aneurysm and renovascular hypertension (RVH). Four years after the first operation, the bypass graft became occluded and hypertension was exacerbated. Magnetic resonance angiography revealed that the left renal artery was supplied by the collateral arteries. We performed replacement of the thoracoabdominal aorta and reconstruction of the left renal artery using the saphenous vein. Postoperatively serum creatinine level decreased and hypertension was controllable. She was discharged from the hospital and has been well for three years.
　Jpn. J. Cardiovasc. Surg. 30：157-160 (2001)

Familial Aortic Dissection: A Report of Four Cases in Two Families 　　S. Tobinaga, et al.…161

Familial Aortic Dissection: A Report of Four Cases in Two Families

(Department of Surgery, Kurume University School of Medicine, Kurume, Japan)

Satoru Tobinaga Hidetoshi Akashi Takayuki Fujino

Shuji Fukunaga Shinsuke Hayashi Tomokazu Kosuga

Koji Akasu Seiji Onitsuka Hideki Sakashita

Shigeaki Aoyagi

There are rare reports of families with multiple members with aortic dissection in the absence of Marfan syndrome. We encountered four cases of aortic dissection in two families. The aortic dissection occurred in the mother and child of the first family and in sisters of the second family. All cases had systemic hypertension preoperatively and presented Stanford type A aortic dissection. All of them were operated successfully. None of them showed the characteristics of connective tissue disease affecting the skeletal, ocular, and cardiovascular system. However, many members of the two families had systemic hypertension and histopathological examination of the aorta showed cystic medial necrosis in all of the four cases. The present study suggests that the familial aortic dissection may be caused by weakness of the aortic wall related to heredity and systemic hypertension.
　Jpn. J. Cardiovasc. Surg. 30: 161-164 (2001)