Japanese Journal of Cardiovascular Surgery Vol.31, No.2

Preoperative Blood Donation in Coronary Artery Bypass Grafting

Etsuro Suenaga Hisao Suda Yuji Katayama Manabu Sato (Department of Cardiovascular Surgery, Nagasaki Kouseikai Hospital, Nagasaki, Japan)

Preoperative blood donation is well known as one approach to reducing complications caused by homologous blood transfusion. The purpose of this study is to evaluate whether preoperative blood donation prior to coronary artery bypass grafting (CABG) reduces homologous blood transfusion. The subjects were selected from 151 consecutive patients who underwent CABG between October 1996 and October 1998. Of the 151 patients, 76 made preoperative blood donations (group A). Results in this group were compared with those obtained in the control group consisting of the subjects who received CABG without preoperative blood donation (group B, n=75). Both groups were matched for age, sex, preoperative hematocrit, cardiopulmonary bypass time, blood transfusion index (BTI; body weight×preoperative hematocrit). There were no significant differences between the two groups in terms of age and mean bypass duration. Homologous blood requirements were significantly lower in group A (78.9%) compared to group B (61.0%). BTI in group A (2,224±447) however, was higher than that in group B (2,129±515). In our study, preoperative blood donation was very effective to reduce homologous blood transfusion in coronary artery bypass grafting. 　　Jpn. J. Cardiovasc. Surg. 31: 97-99 (2002)

Long-Term Results after Surgery for Abdominal Aortic Aneurysm

Masahiko Ikebuchi Kengo Nishimura Maromi Tachibana Teruo Maeda Yasushi Kanaoka Shigetsugu Ohgi (Second Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan)

We evaluated long-term survival and morbidity of 191 patients (161 non-ruptured and 30 ruptured) undergoing abdominal aortic aneurysm repair between 1980 and 1997. Thirty-day mortality rates of non-ruptured and ruptured aneurysms were 1.2% and 36.6%, respectively. Hospital death occurred in 3.1% of patients with non-ruptured aneurysms and 53.3% of those with ruptured aneurysms. Cumulative survival rates after successful AAA repair at 5 and 10 years were 76.3% and 42.3%, respectively. These were lower than survival rates in the age- and gender-matched general population. The most frequent cause of late death was cardiac problems (28.8%) including myocardial infarction. Other causes included stroke (19.2%), malignant neoplasm (17.3%), and ruptured recurrent aneurysms at or above the proximal anastomosis (9.6%) including aorto-enteric fistulas. Regarding late vascular complications, recurrent aneurysms at or above the proximal anastomosis were found in 10% of patients, including 3.5% of true aneurysms, 4.7% of anastomotic aneurysms, and 1.8% of aorto-enteric fistulas. Thoracic aortic aneurysms were found in 3.7% and aortic dissection in 4.2%. Cumulative graft patency rates at 10 and 15 years were 97.4% and 90.9%, respectively. Suppressive treatment for arteriosclerosis and continuous careful follow-up with an aggressive diagnostic approach may reduce morbidity and mortality from recurrent aneurysms or coronary artery disease, thereby improving late survival after AAA surgery. 　　Jpn. J. Cardiovasc. Surg. 31: 100-104 (2002)

Off-Pump Coronary Artery Bypass Grafting in Dialysis Patients

Hiroyuki Tanaka	Takashi Narisawa	Takanobu Mori
Mikio Masuda	Takashi Suzuki	Toshihiro Takaba＊

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

In dialysis cases complicated with ischemic heart disease, there are many problems, such as poor preoperative general condition, calcified aorta, water-electrolyte control, and the necessity for other simultaneous operations. Off-pump coronary artery bypass grafting (OPCAB) was considered very useful in coping with these problems. OPCAB, employed in five cases, was compared with conventional coronary artery bypass grafting with extracorporeal circulation (ECC group, 9 cases). Regarding preoperative coexisting diseases, collagen diseases, porcelain aorta, cerebral infarction, and others were recognized in the OPCAB group in 3 of 5 cases. Emergency operations were performed in 5 of 9 cases in the ECC group, and in 2 of 5 cases in the OPCAB group. The bypass number (3.2 vs. 2.0) and complete revascularization rate (7 of 9 vs. 2 of 5), tended to be higher in the ECC group. The OPCAP group was significantly superior in blood transfusion (6.7 vs. 3.0u), postoperative CK-MB (63 vs. 33u), and the postoperative usual hemodialysis commencing time (4.2 vs. 1.0 day). Concerning use of postoperative IABP (3 of 9 vs. 0 of 5), and postoperative ventilator weaning time (2.7 vs. 1.0 day), a good tendency was shown in the OPCAB group. Although a high mortality rate (2 of 5) was recognized in OPCAB group compared with ECC group (1 of 9), those were urgent cases who had a very poor preoperative condition, and both cases suffered non-cardiac deaths. Excluding special cases, such as an unstable hemodynamic state requiring assisted circulation, and poor coronary run off, OPCAB seems useful for the treatment of coronary artery disease in dialysis patients.　
　　Jpn. J. Cardiovasc. Surg. 31: 105-109 (2002)

Reactivity of the Internal Thoracic Artery Graft to Drugs in Coronary Artery Bypass Grafting

Katsunori Takeuchi	Shigeru Sakamoto
Toshiaki Matsubara	Yasuhiro Nagayoshi
Hisateru Nishizawa	Shinji Shono
Michitaka Kohno	Junichi Matsubara

(Department of Thoracic and Cardiovascular Surgery, Kanazawa Medical University, Ishikawa, Japan)

The internal thoracic artery is a useful conduit for coronary artery bypass grafting (CABG). Recently we have developed a method for increasing blood flow by directly injecting a phosphodiesterase III (PDE III) inhibitor into the left internal thoracic artery (LITA) to inflate the artery and prevent its contraction. In the present study we compared the reactivity of the LITA to three drugs: PDE III inhibitor, papaverine hydrochloride and isosorbide dinitrate (ISDN). Forty-two patients with a mean age of 66.8±11.5 years old who were undergoing primary CABG were enrolled in this study and were randomly separated into one of three groups based on the vasodilating drug administered. Each drug was used in 14 cases. Graft free flow (GFF) and systemic blood pressure were measured before and one minute after drug administration to calculate blood vessel resistance (R). All the drugs significantly increased GFF, and reduced both R and blood pressure. A comparison of the change rate of blood pressure did not differ significantly among the three drug groups. The PDE III inhibitor significantly increased change rates of both GFF and R, compared with the other drugs. These results indicate that PDE III inhibitor is most effective for increasing the blood flow of LITA grafts for CABG.　
　　Jpn. J. Cardiovasc. Surg. 31：110-113(2002)

Prognosis of Stanford Type B Acute Aortic Dissection and Availability of Early Rehabilitation Program in Medical Treatment

Hitoshi Fukumoto	Yasuhisa Nishimoto
Masayoshi Nishimoto	Toshihiko Ibaragi
Shuuichi Suzuki	Akira Fujiwara

(Osaka Mishima Critical Care Medical Center, Takatsuki, Japan)

Stanford type B acute aortic dissection without complications has been considered to be an indication for medical rather than surgical treatment. To investigate the availability of medical treatment and early rehabilitation, we evaluated 90 cases treated between 1986 and 1999 with type B acute aortic dissection. These consisted of 79 nonruptured cases and 11 ruptured cases at the beginning of treatment in our medical center. No surgery was performed in any of the nonruptured cases but surgery was performed in 8 of 11 ruptured cases. Surgical mortality in the rupture type was 12.5% (1/8). During medical treatment of the nonrupture type, 3 patients died of sudden rupture (1 case) and bowel ischemia (2 cases). An early rehabilitation program in which the goal was for the patient to walk around the ward within 2 weeks was performed for 31 consecutive cases of nonrupture type without vascular complications. Mortality was not significantly different between the early and conventional rehabilitation groups. The incidence of pneumonia and ICU syndrome during medical treatment was 13.0% (6/46) and 37% (17/46), respectively in the conventional group and 0% and 12.9% (4/31), respectively in the early group. The incidence of ICU syndrome was significantly lower in the early group than in the conventional group. Despite the limitations of this study, medical treatment and early rehabilitation showed good results in cases of uncomplicated type B acute aortic dissection.　
　　Jpn. J. Cardiovasc. Surg. 31：114-119(2002)

Mid-Term Results of the Use of Radial Artery Graft for Coronary Artery Bypass (Radial Artery Graft Versus Saphenous Vein Graft)

Ryusuke Suzuki	Satoshi Kamata	Katsuhiko Kasahara
Jiro Honda	Toshiya Koyanagi	Hitoshi Kasegawa
Takao Ida	Mitsuhiko Kawase

(Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan)

The use of the radial artery (RA) for coronary artery bypass grafting (CABG) is increasing. This study describes mid-term results of the use of RA for CABG. Between March 1996 and March 1999, we performed 134 CABGs using RA or saphenous vein graft (SVG) for the left circumflex branch area or diagonal branch area. The mean age was 62.6±9.6 years in the RA group and 65.0±7.8 years in the SVG group. The average number of anastomoses was 2.7 per patient. RA was anastomosed with the postero-lateral branch (PL) in 69 cases, with the obtuse marginal branch (OM) in 29 cases and with the diagonal branch (DB) in 10 cases. SVG was anastomosed with PL in 26 cases, with OM in 14 cases and with DB in 2 cases. The proximal anastomosis was made with the ascending aorta in all cases. No sequential bypass anastomosis was used in any case. The early patency rate of the grafts was 97.9% (93/95) in RA and 91.7% (33/36) in SVG. The clinically negative rate in the treadmill test (TMT) performed later was 99.0% (102/103) in RA and 90.9% (30/33) in SVG. The late patency rate of the grafts was 92.9% (13/14) in RA and 50.0% (3/6) in SVG. Perioperative death occurred in 5 cases. Late cardiac death occurred in 2 cases (0.02%) of the RA group and 1 case (0.03%) of the SVG group. The 3 year-survival rate free of cardiac events was 92.8% in the RA group and 80.9% in the SVG group. The use of RA for CABGs is not only effective for myocardial revascularization, but also can be expected to bring about good patency as a late result.　
　　Jpn. J. Cardiovasc. Surg. 31: 120-123 (2002)

A Case of Infective Endocarditis with Septic Pulmonary Emboli

Takayuki Ueno	Toshiyuki Yuda＊	Hitoshi Matsumoto
Yosuke Hisashi	Ryuzo Sakata

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

A 37-year-old woman had a permanent transvenous cardiac pacemaker inserted previously in the left subclavian region to treat complete atrioventricular heart block. As infection occurred in the left subclavian subcutaneous pacemaker pocket after generator replacement, the generator was removed and a new permanent transvenous cardiac pacemaker was inserted in the right subclavian region. After two months, she developed fever and productive cough, and was admitted to our hospital. Echocardiography showed vegetation on the pacemaker electrodes and the tricuspid valve. Chest-computed tomography showed scattered bilateral peripheral nodules with various degrees of cavitation. We diagnosed right-sided infective endocarditis (IE) with septic pulmonary emboli (SPE) and performed cardiac surgery. We observed vegetation on the pacemaker electrodes and the tricuspid valve. The vegetation, the electrodes, and the generator were all removed and a permanent epicardial pacemaker was inserted subcutaneously in the left subcostal region. Methicillin sensitive Staphylococcus aureus (MSSA) was isolated from cultures of vegetation. Postoperative antibiotic therapy was performed and SPE was completely cured. We removed the pacemaker and the electrodes, and performed postoperative antibiotic therapy.　
　　Jpn. J. Cardiovasc. Surg. 31：124-127(2002)

A Successful Surgical Treatment of Distal Arch Aneurysm with Papillary Fibroelastoma in the Left Ventricle

Masahiro Inoue	Osamu Oba	Takeshi Shichijo
Keiji Yunoki

(Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan)

Papillary fibroelastoma is a relatively rare cardiac tumor. A report is presented on a 64-year-old man who was admitted to our institute with dyspnea. Distal arch aneurysm was detected by chest computed tomography and aortography. Preoperative transesophageal echocardiography revealed a tumor 9×5mm in size in the ventricular septum of the left ventricular outflow tract. Total arch replacement and tumor resection were performed. The pathohistological diagnosis of the tumor was papillary fibroelastoma. The postoperative course was uneventful and echocardiography conducted one year postoperatively revealed no recurrence.　
　　Jpn. J. Cardiovasc. Surg. 31: 128-131 (2002)

A Case of Hypertrophic Obstructive Cardiomyopathy with Progressive Heart Failure Due to Ruptured Mitral Chordae Tendineae

Hiromi Yano	Naoki Konagai	Mitsunori Maeda
Masaharu Misaka	Taisuke Matsumaru	Tatsuhiko Kudou
Shin Ishimaru＊

（Department of Cardiothoracic Surgery, Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan and The Second Department of Surgery, Tokyo Medical University＊, Tokyo, Japan)

A 59-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) had been treated by β-blocker for 15 years. Since June 2001 the patient has had symptoms of heart failure on sudden onset. Transesophageal echocardiography showed ruptured mitral chordae tendineae. After medical treatment to improve heart failure, open heart surgery was performed and anterior and posterior ruptured mitral chordae tendineae were recognized. Prosthetic valve replacement was performed. Histopathologic diagnosis of the chordae tendineae was myxoid degeneration. The postoperative course was excellent. Echocardiogram demonstrated that the preoperative left ventricular pressure gradient of 55mmHg reduced to 0 mmHg postoperatively, which indicated that the left ventricular outlet stenosis had disappeared. In patients with HOCM accompanied by ruptured mitral chordae tendineae, early diagnosis by transesophageal echocardiography and timely surgical treatment are essential for successful outcome.　
　　Jpn. J. Cardiovasc. Surg. 31：132-135（2002）

Aortic Valve Replacement and CABG for Aortic Stenosis and Unstable Angina Combined with Active Infective Endocarditis

Naoto Miyagi	Hiroyuki Tanaka	Mikiko Murakami
Koso Egi	Satoru Hasegawa	Makoto Sunamori

（Department of Thoracic and Cardiovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan)

A 59-year-old man who had been treated medically for aortic stenosis and angina pectoris was hospitalized due to a high fever. He was treated immediately by intravenous infusion of antibiotics. Blood culture was positive for α-streptococcus. Echocardiography revealed severe aortic stenosis with vegetation on the aortic valve and minimal aortic regurgitation. The peak aortic pressure gradient was 80 mmHg. The patient developed chest pain at rest and showed ischemic ST-segment depression on the electrocardiogram obtained after admission. Coronary angiography（CAG）was performed to assess the extent of coronary artery disease, and it showed 90% stenosis of the right coronary artery（RCA）and 75% stenosis of the circumflex branch（Cx). Both fever and angina pectoris were so resistant to maximal medical treatment that the patient was referred to our hospital for urgent surgical treatment. During surgery, a large vegetation was noted on the aortic valve, which was calcified, and a destructive ring abscess was observed around the coronary cusp. Aortic valve replacement（SJM-19 mm）was performed after complete debridement of the abscess and repair of the resulting aorto-ventricular discontinuity. Double coronary bypass saphenous vein grafting to RCA and Cx was performed. The patient recovered without incident and was discharged 4 weeks after surgery.　
　　Jpn. J. Cardiovasc. Surg. 31：136-138(2002)

Pitfalls in Open Stent Grafting for Distal Aortic Arch Aneurysm

Kentaro Tamura	Fumikazu Nomura	Shogo Mukai
Katsuhiko Ihara

（Cardiovascular Surgery, National Hospital Kure Medical Center, Hiroshima, Japan)

A 72-year-old woman underwent surgical stent graft implantation for a huge distal arch aneurysm（12×11cm). Axillo-bifemoral bypass was added in order to restore visceral perfusion. Severe metabolic acidosis developed after the operation, and the patient died 6 hours after surgery. Autopsy showed thromboembolism of the superior mesenteric artery and aortic dissection in the descending thoracic aorta because of stent graft insertion into a false lumen. To reduce complications like this case, we should consider the peculiar anatomic features and thoroughly evaluate atheromatous changes in the aortic wall with improvement of the shape of the sheath and delivery system.　
　　Jpn. J. Cardiovasc. Surg. 31：139-142(2002)

A Case of Pseudoaneurysm of the Ascending Aorta, Aortic Stenosis and Regurgitation, and Infected Popliteal Aneurysm Discovered 24 Years after Operation for Subaortic Stenosis

Yuji Naito	Shinya Yokoyama	Imun Tei
Eisei Koh	Keigo Miyata＊	Hiroomi Matsumura＊

(Department of Cardiovascular Surgery and Department of Surgery＊, Kyoto Second Red Cross Hospital, Kyoto, Japan)

We encountered a case of pseudoaneurysm of the ascending aorta, aortic stenosis and regurgitation, and infected popliteal aneurysm discovered 24 years after cardiac operation. A 34-year-old male who had undergone radical operation for subaortic stenosis at age 10 had infectious endocarditis. Pseudoaneurysm of the ascending aorta and aortic stenosis and regurgitation were noticed after diagnosis of a popliteal aneuyrsm, and operation was performed in two stages. Resection of the popliteal aneurysm, direct suturing of the entry as well as resection of the pseudoaneurysm of the ascending aorta, patch plasty of the defect and replacement of aortic valve were performed with satisfactory results.　
　　Jpn. J. Cardiovasc. Surg. 31：143-145(2002)

A Case Report of One-Staged Coronary Artery Bypass Grafting and Revascularization of the Lower Extremities for Severe Ischemic Heart Disease and Leriche's Syndrome

Tatsuichiro Seto	Hiroto Kitahara	Yuko Wada
Tsuneo Nakajima	Takehiko Furusawa	Tamaki Takano
Hirohumi Nakano	Jun Amano

(Second Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan)

A 44-year-old man was given a diagnosis of severe ischemic heart disease and Leriche's syndrome. He had critical ischemia in the lower extremities and ischemic gangrene in a toe of the left foot. We planned a one-stage operation for these fatal diseases. To prevent irreversible ischemia of the lower limbs after mobilization of internal thoracic arteries or during extra-corporeal circulation, we performed aorto-ilio femoral bypass grafting with extra-peritoneal approach first. Then conventional coronary artery bypass grafting was carried out for three coronary arteries with bilateral internal thoracic arteries (ITAs) and the saphenous vein. The postoperative course was uneventful.　
　　Jpn. J. Cardiovasc. Surg. 31：146-149(2002)

A Case of Papillary Fibroelastoma of the Mitral Valve

Kazuma Takeuchi Akio Iwakuma Yutaka Tachikawa Hidehiko Iwahashi Ryuji Zaitsu Michio Kimura (Department of Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka, Japan)

A 45-year-old man was admitted with several histories of cerebral infarction. Transesophageal echocardiography showed a small tumor on the anterior mitral leaflet. Open heart surgery was performed. The tumor was removed including a part of the anterior mitral leaflet and mitral valve plasty was done. The post-operative course was uneventful. Papillary fibroelastoma was diagnosed pathologically. To avoid embolic complication, an early surgical procedure is recommended.　 　　Jpn. J. Cardiovasc. Surg. 31：150-152(2002)

A Successful Case of Axillo-Axillary Bypass Grafting with Mild Hypothermia for High-Risk Subclavian Steal Syndrome

Hideki Kitamura Kengo Nakayama Tadashi Kitano (Department of Cardiovascular Surgery, Shimane Prefectural Central Hospital, Izumo, Japan)

A 67-year-old man, who had suffered from right cerebral infarction that resulted in left hemiparesis, underwent right superficial temporal artery-middle cerebral artery anastomosis in 1991. From March 2000, dizziness occurred during use of his right hand. His arteriogram revealed late filling of the occluded right subclavian artery by reversed flow from the right vertebral artery and 50% stenosis of the left internal carotid artery. We performed subcutaneous axillo-axillary bypass grafting with mild hypothermia on June 1st, 2000. An 8mm ePTFE tube with a ring was anastomosed to both axillary arteries in end-to-side fashion with continuous sutures. Thereafter, symptoms disappeared. One month after the procedure, his arteriogram showed that the bypass filled the right vertebral artery in an antegrade fashion as well as the right axillary artery. Axillo-axillary bypass grafting with mild hypothermia seemed to be safe and effective for high-risk subclavian steal syndrome.　 　　Jpn. J. Cardiovasc. Surg. 31：153-155(2002)

A Case of Mitral Valve Replacement for Mitral Regurgitation Induced by Direct Insertion of the Papillary Muscle into the Anterior Mitral Leaflet with Postinflammatory Disease

Ryuji Higashita	Seiichi Ichikawa
Hiroshi Niinami	Tetsuo Ban
Yuji Suda	Hidetsugu Ogasawara
Yasuo Takeuchi	Shin-ichiro Ohkawa＊

(Department of Cardiovascular Surgery and Department of Internal Medicine＊, Tokyo Women's Medical University Daini Hospital, Tokyo, Japan)

A 71-year-old man had been repeatedly admitted to our hospital with congestive heart failure, cerebral infarction and pneumonia. Under a diagnosis of mitral regurgitation and tricuspid regurgitation by echocardiography and catheter examination, mitral valve replacement and tricuspid annuloplasty were performed. Pathohistological study revealed a direct insertion of the papillary muscle into the anterior mitral leaflet (DPM) in addition to post-rheumatic valvular disease. These findings suggest that the increased rigidity of the scarring valve leaflets in combination with direct insertion of DPM lead to inadequate leaflet coaptation and apposition. This is the first report of mitral valve replacement for mitral regurgitation due to postinflammatory valvular disease with DPM.　
　　Jpn. J. Cardiovasc. Surg. 31: 156-159 (2002)

Three Cases of Ruptured Abdominal Aortic Aneurysm Treated Successfully by the Retroperitoneal Approach

Takeshi Uzuka	Johji Fukada
Kiyofumi Morishita	Nobuyoshi Kawaharada
Ryuji Koshima	Akihiro Tabata
Tomio Abe

(Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan)

The retroperitoneal approach for abdominal aortic aneurysm（AAA）has been used to reduce the risk of postoperative ileus and respiratory failure. This technique is usually used in patients with non-ruptured infrarenal AAA because it has been considered to be more time consuming to approach the aorta than the normal transabdominal approach. However, we may not have sufficient information if the aneurysm is confined to the infrarenal abdominal aorta in a ruptured case. In such a situation, the retroperitoneal approach might be better than the transabdominal approach because an aortic clamp can easily be applied to the suprarenal aorta. We report three cases of ruptured AAA treated successfully by the retroperitoneal approach.
　　Jpn. J. Cardiovasc. Surg. 31：160-162(2002)

A Case of Mitral Valve Papillary Fibroelastoma Leading to Transient Ischemic Attack（TIA）

Takeo Suzuki	Yutaka Imoto	Yoshikazu Tsuruhara
You-Ping Wang	Hajime Maeta

（First Department of Surgery, Kagawa Medical University, Kagawa, Japan)

We report a case of surgical treatment for mitral valve papillary fibroelastoma which is an uncommon and rare benign tumor. The patient was a 62-year-old woman who had TIA（paralysis of left leg）and was admitted with the diagnosis of cardiac tumor. Before operation, the tumor was detected in the left atrium two-dimensional echocardiography, attached to the anterior leaflet of the mitral valve. At operation, the tumor was 11×8mm in size, with a yellow jelly-like and fragile appearance, attached to the same position as indicated by echocardiography. As the tumor occupied over one third of the leaflet, it was excised including all the anterior leaflet of the mitral valve and a prosthetic valve was replaced leaving the posterior leaflet intact. The tumor was diagnosed as papillary fibroelastoma by pathological examination. The postoperative course was uneventful.　
　　Jpn. J. Cardiovasc. Surg. 31：163-166(2002)