Japanese Journal of Cardiovascular Surgery Vol.30, No.6

Originals

  • Long-term Results of the St. Jude Medical Valve in the Tricuspid Position 　　T. Shichijo, et al.……277
    Long-term Results of the St. Jude Medical Valve in the Tricuspid Position

    (Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan)
    Takeshi Shichijo Osamu Oba Keiji Yunoki
    Masahiro Inoue
    From 1983 to 1999, 12 St. Jude Medical prostheses were implanted in the tricuspid position. Mean patient age at the time of operation was 40±19(6 to 62) years. Seven patients were female and five were male. There were no hospital deaths but three late deaths. The cumulative survival rate was 100% at 5 years, 80% at 10 years and 60% at 15 years. Four patients required redo tricuspid valve replacement because of a thrombosed valve. The reoperation-free rate was 100% at 5 years, 78% at 10 years and 29% at 15 years. The data illustrated that patients who underwent tricuspid valve replacement with the St. Jude Medical valve should receive strict anticoagulation therapy.
    　Jpn. J. Cardiovasc. Surg. 30: 277-279 (2001)
  • Strategy for Stanford Type A Acute Aortic Dissection with Thrombosed False Lumen of the Ascending Aorta 　　H. Obo, et al.……280
    Strategy for Stanford Type A Acute Aortic Dissection with Thrombosed False Lumen of the Ascending Aorta

    (Department of Cardiovascular Surgery, Himeji Brain and Heart Center, Hyogo, Japan)
    Hidefumi Obo Tsutomu Shida Syuuichi Kozawa
    Tatsurou Asada Nobuhiko Mukohara Tetsuya Higami
    Kazuhiko Iwahashi Teruo Yamashita Kyouichi Ogawa
    From 1995 till 1998, 21 cases of Stanford type A dissecting aortic aneurysm with a closed false lumen of the ascending aorta were treated in our institute. The patients were medically treated if the diameter of their ascending aorta stayed less than 50mm without recurrent dissection. Patients were categorized into three groups: Groups I, II and IIIR (retrograde dissection), according to the location of the entry analyzed by means of CT, angiography and operative findings. Seven cases of intramural hematoma (IMH) were included in this study. One case in Group II died of rupture and one case in Group IIIR died of multiple embolism caused by atrial fibrillation in the acute phase. One case in Group II died of stroke and one case in Group I died after surgery in the chronic phase. Four cases in Group I and II underwent surgery in the acute phase and five cases in Group I and II underwent surgery in the chronic phase, but only one case of Group IIIR required surgery. Six cases of IMH required surgery. The rates of freedom from operation at four years was 25%, 21% and 83% respectively (p＝0.07). Essentially, Stanford type A dissection should be treated surgically even though the false lumen is thrombosed. However, in the case of retrograde dissection accompanied by an entry in the descending aorta, medical treatment may be a strategy option.
    　Jpn. J. Cardiovasc. Surg. 30: 280-284 (2001)
  • Surgical Strategy for Thoracic Aortic Aneurysm with Abdominal Aortic Aneurysm 　　H. Furukawa, et al.……285
    Surgical Strategy for Thoracic Aortic Aneurysm with Abdominal Aortic Aneurysm

    (Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan)
    Hiroshi Furukawa Shigeyuki Aomi Yasutaka Ueno
    Satoshi Noji Kazuhiko Uwabe Shinichiro Kihara
    Hisao Kurihara Akihiko Kawai Hiroshi Nishida
    Masahiro Endo Hitoshi Koyanagi
    We evaluated the surgical strategy for thoracic aortic aneurysm associated with abdominal aortic aneurysm. From January 1982 to March 1999, 24 consecutive patients underwent surgical treatment for thoracic aortic aneurysm with abdominal aortic aneurysm. Staged operation was performed if one was only slightly dilated, but extensive operation was needed if the size of both aneurysms was greater than 6cm. In cases of thoracic aortic aneurysm with abdominal aortic aneurysm up to 4cm in size, surgical treatment was performed only for the thoracic aortic aneurysm. Circulatory support during operation was established from the ascending aorta, and circulatory arrest with deep hypothermia and retrograde cerebral perfusion were used for brain protection during surgery for thoracic aortic arch aneurysm. Hospital mortality was 12.5% (3/24 cases). The causes of death were cerebral infarction and respiratory failure. Antegrade systemic perfusion and aortic no-touch technique were an effective method of surgery for thoracic aortic aneurysm with abdominal aortic aneurysm to avoid perioperative embolism and major complications. We successfully performed staged operation, but regular radiographic follow-up was needed.
    　Jpn. J. Cardiovasc. Surg. 30: 285-289 (2001)
  • Effects of Modified Ultrafiltration in Pediatric Cardiac Surgery 　　K. Miyamoto, et al.……290
    Effects of Modified Ultrafiltration in Pediatric Cardiac Surgery

    (Cardiac Surgery, Kumamoto City Hospital, Kumamoto, Japan)
    Kazuyuki Miyamoto Kunihiro Yonenaga Touitsu Hirayama
    Ichiro Ideta
    Modified ultrafiltration (MUF) for cardiopulmonary bypass (CPB) in children decreases total body water and improves left heart function. We investigated the effects of MUF in pediatric open-heart surgery. Eighty-six patients less than 15kg who underwent radical cardiac operation were divided into four groups according to whether they received transfusion during the operation or not, and whether MUF was performed after completion of CPB or not. MUF group showed significantly higher hematocrit levels 20 min after the end of CPB compared with non-MUF group in both transfused group and non-transfused group. Then, MUF group showed a significantly higher serum protein level than non-MUF group. In MUF groups, the systolic blood pressure elevated without the elevation of the left atrial pressure. We calculated PaO2/FiO2 as an index of postoperative lung function. The postoperative PaO2/FiO2 of MUF group was significantly higher than that of non-MUF group in transfused group. MUF significantly decreased homologous blood transfusion during the operation. MUF after CPB elevated hematocrit level and serum protein level, and improved cardiac function without volume load. Since MUF reduced the need for homologous blood transfusion. MUF is a useful means for pediatric cardiac surgery.
    　Jpn. J. Cardiovasc. Surg. 30: 290-294 (2001)

Case Reports

  • A Successful Case of Endovascular Stent Graft Treatment to Sealed Rupture of an Abdominal Aortic Aneurysm in an Elderly Patient 　　A. Sasaki and J. Sakata……295
    A Successful Case of Endovascular Stent Graft Treatment to Sealed Rupture of an Abdominal Aortic Aneurysm in an Elderly Patient

    (Division of Cardiovascular Surgery, Sunagawa Medical Center, Sunagawa, Japan)
    Akihiko Sasaki Junichi Sakata
    We carried out endovascular stent graft implantation in a patient aged 89 years to sealed rupture of an infrarenal abdominal aortic aneurysm. He had received left ilio-femoral bypass, femoro-femoral cross over bypass and bilateral femoro-popliteal bypass due to ASO in 1989. The infrarenal abdominal aortic aneurysm accompanied with a large hematoma was 4 cm in maximum diameter and reached 4 cm above the bifurcation. There was extravasation into the retroperitoneal space at the proximal aortic neck. We made a stent graft from a Z stent (30mm, 7.5cm) and straight thin-walled (0.15mm) graft (24mm). It was introduced at just below the left renal artery through a 22F delivery sheath by the femoral cut-down approach. Following this procedure he had no leaks and the abdominal aortic aneurysm was excluded by stent graft.
    　Jpn. J. Cardiovasc. Surg. 30: 295-298(2001)
  • An Adult Case of Isolated Mitral Regurgitation Associated with Marfan's Syndrome 　　H. Fukuda, et al.……299
    An Adult Case of Isolated Mitral Regurgitation Associated with Marfan's Syndrome

    (Department of Cardiovascular Surgery, Sakurabashi-Watanabe Hospital, Osaka, Japan)
    Hirotsugu Fukuda Yuji Miyamoto Hiroshi Takami
    Kenji Onishi
    A 32-year-old woman with Marfan's syndrome who had had a heart murmur in childhood was admitted due to congestive heart failure. Her echocardiography showed anterior and posterior leaflet prolapse of the mitral valve, and also severe mitral valve regurgitation. Her chest CT scan showed no evidence of an enlarged ascending aorta. We performed mitral valve replacement using a mechanical valve, because the long-term results of mitral valve repair for Marfan's syndrome are unknown. We reviewed the literature for other examples of this rare adult case with isolated mitral regurgitation associated with Marfan's syndrome.
    　Jpn.J. Cardiovasc. Surg. 30: 299-301(2001)
  • Surgical Removal of a Right Atrial Thrombus Complicated with Long-term Use of a Venous Port Using a PCPS (Percutaneous Cardiopulmonary Support) Kit 　　H. Shikata, et al.……302
    Surgical Removal of a Right Atrial Thrombus Complicated with Long-term Use of a Venous Port Using a PCPS (Percutaneous Cardiopulmonary Support) Kit

    (Department of Thoracic and Cardiovascular Surgery, Kanazawa Medical University, Ishikawa, Japan)
    Hiroo Shikata Shigeru Sakamoto Hisateru Nishizawa
    Shinji Shono Toshiaki Matsubara Junichi Matsubara
    A 15-year-old boy who had been treated for TOF (tetralogy of Fallot) at 3 years of age was admitted with dysphagia due to esophageal stenosis. He also suffered from malrotation of the intestine. The esophageal stenosis was caused by recurrent cyclic vomiting and subsequent esophagitis. Three years earlier, he had received an implantation of a totally implantable central venous access device via the right cephalic vein. Echocardiography revealed a floating mass in his right atrium, which was assumed to be a thrombus at the catheter tip of the central venous access device. We suspected that the cause of atrial thrombus in this case was complicated by the long-term (3 years) use of the venous central port. He was suspected to have a pulmonary embolism. A perfusion lung scan (99mTc-MAA) revealed multiple diminished uptake in both lungs. The thrombus was removed successfully under partial cardiopulmonary bypass. The postoperative course was uneventful.
    　Jpn. J. Cardiovasc. Surg. 30: 302-304(2001)
  • A Case of Ruptured Coronary Artery Aneurysm Associated with Coronary Artery Fistulas 　　N. Murata and N. Yamamoto……305
    A Case of Ruptured Coronary Artery Aneurysm Associated with Coronary Artery Fistulas

    (Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan)
    Noboru Murata Noboru Yamamoto
    We reported a successfully operated case of ruptured coronary artery aneurysm which resulted from a coronary artery fistula. A 70-year-old woman who had been treated for hypertension developed syncope and profound shock. Echocardiography and chest CT-scan suggested the presence of cardiac tamponade. An emergency operation was done. An aneurysm was seen at the left side of the right heart outflow and pulmonary artery, on the proximal left anterior descending coronary artery. Closure of the orifice of the inflow and the outflow vessels of the aneurysm, and aneurysmorraphy was performed under cardiopulmonary bypass. Serpentine small arteries were found around the aneurysm and were simply ligated by mattress sutures. The postoperative course was uneventful, and coronary angiographic study demonstrated normal coronary distribution.
    　Jpn. J. Cardiovasc. Surg. 30: 305-307 (2001)
  • Perivalvular Leakage after Aortic Valve Replacement with a FreestyleTM Stentless Valve 　　T. Kiji, et al.……308
    Perivalvular Leakage after Aortic Valve Replacement with a FreestyleTM Stentless Valve

    (Department of Cardiovascular Surgery, Ishinkai Yao General Hospital, Osaka, Japan)
    Tatsuya Kiji Akimitsu Yamaguchi Hiroshi Kumano
    A 67-year-old man with aortic insufficiency underwent aortic valve replacement (AVR) with a FreestyleTM valve (Medtronic Inc.), using the complete subcoronary technique. Although a trivial aortic insufficiency remained on postoperative echocardiography, he continued without chest symptoms. A cardiac murmur developed and dyspnea on effort appeared five months postoperatively. Echocardiography and aortography showed severe aortic insufficiency, and a re-do AVR was performed seven months after the first procedure. Examination of the Freestyle valve revealed that two loops of the suture line on the inflow side of the valve had become detached from the muscular tissue. It is most important to keep the geometry of the Freestyle valve at the time of the implantation using the subcoronary technique, and an unsuitable implantation can cause consequent perivalvular leakage.
    　Jpn. J. Cardiovasc. Surg. 30: 308-310 (2001)
  • A Surgical Case of Acute Aortic Dissection with Antiphospholipid Syndrome 　　T. Nakajima, et al.……311
    A Surgical Case of Acute Aortic Dissection with Antiphospholipid Syndrome

    (The Second Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan)
    Tsuneo Nakajima Hiroto Kitahara Tetsuya Kono
    Keizo Ohta Tamaki Takano Ryo Hasegasa
    Hirohisa Goto Hirofumi Nakano Hideo Kuroda
    Jun Amano
    The patient was a 52-year-old man with a history of antiphospholipid syndrome (APS), renal dysfunction and myasthenia gravis(MG). On May 2, 1998, he had sudden chest pain while sleeping. Enhanced computed tomography revealed acute aortic dissection (DeBakey type I). We performed emergency graft replacement of the ascending aorta and the aortic arch under extracorporeal circulation. Because of perioperative anuria, we used peritoneal dialysis (PD) just after the operation. Two days after the operation, we performed re-intubation nine hours after the extubation of the tracheal tube, and performed re-extubation three days later. For a while, his postoperative course was uneventful, but because of gradual worsening of APS, we administered more prednisolone, but 74 days after the operation, he died of multiple organ failure caused by an opportunistic infection, sepsis, and disseminated intravascular coagulation. This was very rare case of acute aortic dissection with MG and APS. After administration of more glucocorticoids, it is important to be wary of opportunistic infections.
    　Jpn. J. Cardiovasc.Surg. 30: 311-313(2001)
  • A Surgical Case of Acute Pulmonary Thromboembolism with Multiple Mononeuritis 　　T. Nakajima, et al.……314
    A Surgical Case of Acute Pulmonary Thromboembolism with Multiple Mononeuritis

    (The Second Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan)
    Tsuneo Nakajima Hirofumi Nakano Kuniyoshi Watanabe
    Tamaki Takano Ryo Hasegawa Hirohisa Goto
    Hiroto Kitahara Hideo Kuroda Jun Amano
    The patient was a 63-year-old man with a history of multiple mononeuritis with hypergammaglobulinemia since 1980. The symptoms gradually worsened, and he had been bed-ridden since 1992. On February 28, 1997, he had sudden dyspnea after defecation. Echocardiography demonstrated a large thrombus in the right atrium and the right ventricle. Enhanced chest computed tomography revealed thrombi in the bilateral pulmonary arteries. The patient was considered to have acute pulmonary thromboembolism, and an emergency operation was indicated. Thrombectomy was performed under extracorporeal circulation through a median sternotomy. No thrombi were found in the right atrium or the right ventricle, and thrombi in the bilateral pulmonary arteries were removed completely. Four days after the operation, a Greenfield filter was implanted in the vena cava inferior because venography detected a thrombus in the right common iliac vein. The postoperative course was uneventful. No pulmonary rethromboembolisms were noticed after the operation. The long duration of being bed-ridden seemed to be the chief cause of thrombosis in the deep veins, and hyperviscosity due to hypergammaglobulinemia may have caused hyperthrombogenicity.
    　Jpn. J. Cardiovasc. Surg. 30: 314-316(2001)
  • Mesenteric Ischemia Complicated with Acute Aortic Dissection: Report of a Case with Successful Surgical Management 　　M. Kobayashi, et al.……317
    Mesenteric Ischemia Complicated with Acute Aortic Dissection: Report of a Case with Successful Surgical Management

    (Second Department of Surgery, Yamanashi Medical University, Yamanashi, Japan)
    Masahiro Kobayashi Keiji Iyori Syunya Sindou
    Kihatirou Kamiya Yusuke Tada
    An emergency saphenous vein bypass was performed from the right internal iliac artery to the superior mesenteric artery for ischemia due to occlusion of the superior mesenteric artery complicated with acute DeBakey type I aortic dissection. A 68-year-old woman underwent ascending aortic graft replacement for acute aortic dissection as emergency procedure. On postoperative day 4, signs and symptoms of acute mesenteric ischemia clearly developed. Laparotomy was performed and the saphenous vein graft was used to bypass the right internal iliac artery and the superior mesenteric artery at the orifice of the ileocolic artery where it was free from dissection. Because of persistent diarrhea and cramping abdominal pain, second- and third-look operations were necessary in order to confirm the recovery of intestinal viability. The patient was discharged from hospital with complete relief of abdominal symptoms 110 days after the first operation.
    　Jpn. J. Cardiovasc. Surg. 30: 317-320（2001)
  • Total Arch Replacement for Blunt Traumatic Aortic Injury Associated with Spine Fractures: A Case Report 　　M. Shinonaga, et al.……321
    Total Arch Replacement for Blunt Traumatic Aortic Injury Associated with Spine Fractures: A Case Report

    (Department of Thoracic and Cardiovascular Surgery and Emergency and Critical Care Medical Center＊, Niigata City General Hospital, Niigata, Japan)
    Mayumi Shinonaga Hiroshi Kanazawa Satoshi Nakazawa
    Toshimi Ujiie Yoshihiko Yamazaki＊ Akitoshi Oda＊
    Hidenori Kinoshita＊ Yasuo Hirose＊
    An 80-year-old man was transferred to our hospital because of blunt traumatic aortic arch injury caused by a fall. Computed tomography (CT) revealed a pseudoaneurysm and mediastinal hematoma around the aortic arch, right hemothorax, left hemopneumothorax, lung contusion and spine fractures. His hemodynamic condition was stable but he required mechanical ventilation because of severe hypoxemia. Surgery was postponed until twelve days after the injury, when his lung function improved and active bleeding decreased. During surgery we found that the intimal disruption extended to half of the circumference of the aortic arch, and thus performed total arch replacement under deep hypothermic circulatory arrest and selective cerebral perfusion. The patient suffered respiratory failure and pneumonia postoperatively as well as multiple cerebral infarctions. He was referred to a rehabilitation center on postoperative day 130.
    　Jpn. J. Cardiovasc. Surg. 30: 321-323 (2001)
  • Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) with Intramural Aortic Route 　　Y. Hoshino, et al.……324
    Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) with Intramural Aortic Route

    (Department of Cardiovascular Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan)
    Yuji Hoshino Fumio Iwaya Tsuguo Igari
    Hirono Satokawa Takashi Ono Shinya Takase
    Kazuya Sato Yukitoki Misawa Toshiki Watanabe
    We report a 5-year-old girl with a diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery with an intramural aortic route. The left coronary artery entered the aortic wall running parallel to the aorta. With the aid of cardiopulmonary bypass, she underwent establishment of two coronary artery systems by intraaortic reconstruction (unroofing and anastomosis). Her postoperative course was uneventful. Postoperative cineangiogram demonstrated patency and prograde flow in the new coronary systems.
    　Jpn. J. Cardiovasc. Surg. 30: 324-326(2001)
  • Off-pump CABG and Right Axillo-bifemoral Artery Bypass in a Patient with Totally Calcified Ascending Aorta and Leriche's Syndrome 　　K. Ogata, et al.……327
    Off-pump CABG and Right Axillo-bifemoral Artery Bypass in a Patient with Totally Calcified Ascending Aorta and Leriche's Syndrome

    (Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Fukushima, Japan)
    Koji Ogata Koji Tsuchiya Hideki Ozawa
    Hideki Sasaki Narutoshi Hibino
    A 40-year-old man was admitted because of coronary heart disease with a totally calcified ascending aorta and Leriche's syndrome. Establishing a cardiopulmonary bypass seemed to be difficult because neither the ascending aorta nor femoral artery was suitable as a cannulation site. It was not until a prosthetic conduit for revascularization of the lower extremities was anastomosed to the right axillary artery in preparation for the conversion from off-pump to on-pump that off-pump CABG was performed. Subsequently revascularization of the lower extremities was completed. The patient had a satisfactory postoperative course. Off-pump CABG is useful for patients with a severely calcified ascending aorta and occlusive lesions below the descending aorta.
    　Jpn. J. Cardiovasc. Surg. 30: 327-330 (2001)