Japanese Journal of Cardiovascular Surgery Vol.31, No.6

Originals

Preoperative Evaluation of Right Gastroepiploic Artery with CT-Angiography 　　S. Maeba, et al.…377

Preoperative Evaluation of Right Gastroepiploic Artery with CT-Angiography

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

Satoru Maeba Yasushi Kawaue Tatsuya Nakao

It is a common notion that the right gastroepiploic artery (RGEA) tends to exhibit more hardening than the internal thoracic artery (ITA) and that it shows varied development among patients, since RGEAs are structurally rich in musculature. Therefore, a preoperative examination should be conducted to determine whether or not they are appropriate for grafting. In general, catheter-angiography is widely employed for such examinations. Our recent research on the availability of CT-angiography as an alternative has revealed that CT-angiography is a minimally-invasive, simple way of testing, and provides very clear and detailed angiographical pictures. We therefore concluded that it was a highly effective method in deciding the appropriateness of RGEA for graft.
　Jpn. J. Cardiovasc. Surg. 31：377-381 (2002)

Pacemaker Implantation for Atrial Fibrillation with Bradycardia in Patients with Mitral Valve Disease 　　Y. Ko, et al.…382

Pacemaker Implantation for Atrial Fibrillation with Bradycardia in Patients with Mitral Valve Disease

(Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan and Department of Cardiovascular Surgery, Kashiwa Hospital, Tokyo Jikei University School of Medicine*, Kashiwa, Japan)

Yoshihiro Ko Shigeki Horikoshi* Asatoshi Mizuno*

Isao Aoki* Shingo Taguchi*

Some cases of atrial fibrillation and bradycardia show improvement in slow ventricular response after valvular surgery. However, there is still no established view regarding the indications of pacemaker implantation for the bradyarrhythmia with valvular disease. In 24 cases (permanent pacing group: 15, non-pacing group: 9) of those with bradyarrhythmia who were fitted with a myocardial pacing lead at the time of valvular surgery, we examined predictions of pacemaker implantation and the role of valvular surgery for the bradyarrhythmia. The permanent pacing group showed much larger values than the non-pacing group in regard to preoperative NYHA, right and left atrial pressure, and duration of atrial fibrillation. After valvular surgery, many cases that had significantly decreased left atrial pressure after operation improved with regard to bradycardia. We should judge the indication of pacemaker implantation after valvular surgery from the evaluation of preoperative hemodynamics and early postoperative cardiac function. Because atrial fibrillation tends to accompany bradycardia due to chronic atrial load, we must make an effort to promote the rapid recovery of cardiac function by doing valvular surgery as early as possible.
　Jpn. J. Cardiovasc. Surg. 31：382-384 (2002)

Mid-Term Pulmonary Homograft Function for Right Ventricular Outflow Tract Reconstruction in the Ross Procedure 　　K. Nomura, et al.…385

Mid-Term Pulmonary Homograft Function for Right Ventricular Outflow Tract Reconstruction in the Ross Procedure

(Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan)

Koji Nomura Hiromi Kurosawa Kiyozo Morita

Hirokuni Naganuma Katsushi Kinouchi

Fourteen patients (mean age 17.2 years, range 2 to 39 years) undergoing right ventricular outflow tract reconstruction for a Ross operation were studied between 1998 and 2000. Ten of 14 patients underwent Ross procedures and 4 received Ross-Konno procedures. Echocardiographic examination of the pulmonary homograft was performed after surgery. The mean follow-up period was 23.1 months, ranging from 14 to 33 months. Mean peak velocity and peak gradient were 1.6±0.4m/s and 11.9±5.2mmHg, respectively. Three patients in whom echocardiography revealed a peak pulmonary gradient of 20mmHg or more were retrospectively analyzed with each catheterization data. All patients had no more than 10mmHg at the distal end of the homograft with no evidence of deformity or shrinkage. Only one patient had a trivial homograft valve regurgitation, however, no patient had more than mild pulmonary regurgitation. Patient age, donor age, and preservation period did not reveal any significant risk factor for homograft stenosis. Pulmonary homograft appears to be an excellent substitute for right ventricular outflow tract reconstruction during the mid-term postoperative period.
　Jpn. J. Cardiovasc. Surg. 31：385-387 (2002)

Case Reports

A Case Report of Double Aortic Arch, Vascular Ring Associated with Tracheal Stenosis 　　K. Daitoku, et al.…388

A Case Report of Double Aortic Arch, Vascular Ring Associated with Tracheal Stenosis

(Department of Surgery I, Hirosaki University School of Medicine, Hirosaki, Japan)

Kazuyuki Daitoku Koh Takeuchi Hiroyuki Itaya

Kazuo Itoh Ikkoh Ichinoseki Masayuki Koyama

Kozo Fukui Shunichi Takaya

We report a case of vascular ring with tracheal stenosis, which might be related to a prolonged endotracheal intubation. A symptomatic 2-month-old boy was admitted to our institution after prolonged intubation without a definite diagnosis. His symptoms were stridor and dyspnea, but not dysphagia. Echocardiography detected a vascular ring and this was confirmed by computed tomography and magnetic resonance imaging (MRI) (Edwards IA type). The left anterior aortic arch was divided distal to the left subclavian artery through left thoracotomy and the ligamentum arteriosus was not identified. On postoperative day (POD) 2, endotracheal extubation was unsuccessfully attempted. Further examination such as MRI and bronchoscopy revealed intimal hyperplasia of the trachea with mild compression of the trachea from the outside. We performed aortopexy and division of the small long ductus which might not be a mechanism of the tracheal compression through right thoracotomy in the second operation with successful extubation on POD 3. The patient has been discharged from the hospital and followed up at the outpatient clinic without any symptom. Tracheomalacia was a common associated anomaly in vascular ring. However, other mechanisms such as inflammatory reaction associated with prolonged intubation should be considered and be avoided in the pediatric population.
　Jpn. J. Cardiovasc. Surg. 31：388-391(2002)

Severe Hemolysis after Mitral Valve Plasty: A Case Report of Reoperation with Mitral Valve Replacement 　　Y. Watanabe, et al.…392

Severe Hemolysis after Mitral Valve Plasty: A Case Report of Reoperation with Mitral Valve Replacement

(Department of Cardiovascular Surgery, Higashitoride Hospital, Toride, Japan and Toyogami Clinic*, Chiba, Japan)

Yutaka Watanabe Shonosuke Matsushita Shuichi Okawa

Keisuke Yamabuki Seigo Gomi Teruo Hiyama

Hidemi Kaneko*

A 78-year-old woman, after mitral valve repair by placement of No.29 Duran annuloplasty ring 6 years previously at another hospital, was admitted because of chronic heart failure and hemolytic anemia. A Doppler echocardiogram showed that mitral regurgitation was still present but not severe. The diagnosis of hemolysis was made by decreased serum haptoglobin, elevated serum lactate dehydrogenase (LDH) and progressive anemia. We estimated that the mechanism of hemolysis was related to the mitral annuloplasty with a ring and improvement of symptoms would be impossible without removal of the ring. On 25 June, 2001, the reoperation was performed through a median sternotomy, but adhesion was so severe that a standard left atriotomy was impossible. Therefore, the right thoracic cavity was opened through a mediastinal pleurotomy and a transseptal approach was taken through right atriotomy. The annuloplasty ring was partially detached from the mitral valve ring, and that part was non-endothelialized. We concluded that an eccentric regurgitant blood stream directed to the non-endothelialized portion of the annuloplasty ring appeared responsible for the hemolysis. The ring was removed and mitral valve replacement was performed with a 25mm Carpentier Edwards bioprosthesis. The removal of the source of hemolysis and the mitral valve replacement allowed prompt recovery from severe hemolysis. Decreased serum haptoglobin, elevated LDH and progressive anemia recovered postoperatively. The reoperation used was safe and effective in relieving hemolysis. The scanty literature concerned was reviewed.
　Jpn. J. Cardiovasc. Surg. 31：392-394(2002)

Successful Surgical Correction of an Incomplete Endocardial Cushion Defect in an Elderly Patient 　　T. Saito, et al.…395

Successful Surgical Correction of an Incomplete Endocardial Cushion Defect in an Elderly Patient

(Department of Cardiovascular Surgery, Mito National Hospital, Mito, Japan and Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University*, Sendai, Japan)

Takeshi Saito* Naoki Uchida Junitu Akasaka*

Goro Takahashi*

A successful surgical correction of an incomplete endocardial cushion defect (ECD) with an ostium primum defect in a 63-year-old man is reported. Incomplete ECD with ostium primum defect often causes severe heart failure in infancy. Reports of its surgical correction in elderly patients are few. The patient had upper abdominal discomfort and grade 1 mitral valve regurgitation. The preoperative diagnosis was complete ECD (Rastelli typeA) because we misdiagnosed a leakage from a cleft between the left superior leaflet and the left inferior leaflet for a flow through a ventricular septal defect when we analyzed a preoperative left ventriculography. The importance of not misdiagnosing the leakage and echocardiography in preoperative diagnosis of ECD was therefore realized. The operative procedure involved patch closure of the ostium primum defect and mitral valve annuloplasty by Kay's procedure and the mitral valve regurgitation completely disappeared. The postoperative course was uneventful. The upper abdominal discomfort and cardiomegaly improved. If there is no severe dysfunction of other organs, surgical correction of incomplete ECD should be recommended even for elderly patients.
　Jpn. J. Cardiovasc. Surg. 31：395-398 (2002)

A Case of Modified Aortic Root Remodeling for Valsalva Aneurysms of the Right and Noncoronary Sinuses 　　T. Yamazaki, et al.…399

A Case of Modified Aortic Root Remodeling for Valsalva Aneurysms of the Right and Noncoronary Sinuses

(Department of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan)

Takenori Yamazaki Kouji Sakurai Hiroaki Hagiwara

Masaharu Yoshikawa Toshiaki Itou Toshiaki Akita

You Yano Toshio Abe

A 61-year-old woman had extracardiac unruptured aneurysms of the right and noncoronary sinuses of Valsalva, detected incidentally on electrocardiogram taken for a physical checkup. Two-dimensional echocardiography revealed that the sizes of the aneurysm of the right and noncoronary sinuses were 41×40 and 38×28mm respectively, but the shape of left coronary sinus was almost normal. The aortic valve leaflet was normal and the diameter of the aortic annulus and sinotubular junction was 23 and 27mm respectively. The Doppler color-flow echocardiogram showed moderate aortic regurgitation which resulted in prolapse of the right aortic cusp due to deformity of the annulus. We performed modified aortic root remodeling using a tailored Dacron graft to preserve the native aortic valve. Right and noncoronary sinuses of Valsalva were all excised with a small button of the aortic wall around the ostia of the right coronary artery. The left coronary sinus was left as it was. Then each commissure received sub-commissural annuloplasty and was pulled up. The defect of Valsalva was reconstructed with a 26mm Dacron tube graft, the proximal end of which was tailored to a scallop shape and that correspond to left coronary sinus was excised. The right coronary artery was reimplanted utilizing the Carrel patch method. Although we needed additional CABG to the right coronary artery and IABP support due to vasospasm of the right coronary artery, the postoperative course was uneventful. Echocardiography of the aortic valve before discharge showed a normal function without regurgitation.
　Jpn. J. Cardiovasc. Surg. 31：399-403 (2002)

Coarctation of the Abdominal Aorta Associated with Aneurysm of the Descending Thoracic Aorta Probably due to Aortitis Syndrome 　　M. Aiba, et al.…404

Coarctation of the Abdominal Aorta Associated with Aneurysm of the Descending Thoracic Aorta Probably due to Aortitis Syndrome

(First Department of Surgery, School of Medicine, Showa University, Tokyo, Japan)

Masahiro Aiba Tadanori Kawada Atsuyoshi Oki

Katsuyoshi Iyano Kazuto Maruta Susumu Takeuchi

Yasuhiro Shiojiri Masahiko Shibata Toshihiro Takaba

A 67-year-old woman had left lateral chest pain. CT scan and digital subtraction angiography revealed coarctation of the abdominal aorta just distal from the renal artery and a fusiform aneurysm of the descending thoracic aorta with a maximum diameter of 60mm. The meandering mesenteric artery was significantly dilated as a collateral vessel from the superior mesenteric artery to the inferior mesenteric artery. Aortitis syndrome was suspected from the angiographic findings although inflammatory changes in laboratory data were not observed. She underwent aneurysmectomy followed by prosthetic graft replacement of the descending thoracic aorta under femoro-femoral bypass and an extraanatomical bypass grafting from the replaced graft to the abdominal aorta proximal to the aortic bifurcation via the retroperitoneal space. She was discharged on the 42nd day after operation without any complications and in the past year has returned to her usual daily life without any anastomotic site trouble.
　Jpn. J. Cardiovasc. Surg. 31：404-407 (2002)

Off-Pump Coronary Artery Bypass Grafting via Left Thoracotomy in a Patient with Esophageal Cancer 　　M. Mohri, et al.…408

Off-Pump Coronary Artery Bypass Grafting via Left Thoracotomy in a Patient with Esophageal Cancer

(Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan)

Makoto Mohri Takeo Tedoriya Mikizo Nakai

Kozo Ishino Shunji Sano

A 71-year-old man with early-stage esophageal cancer underwent off-pump coronary artery bypass grafting (CABG) through left thoracotomy to avoid sternotomy to allow subsequent esophageal surgery. The patient had severe double vessel coronary artery disease (the left anterior descending artery and the right coronary artery). Esophageal pull-out resection and reconstruction with the transverse colon over the sternum were planned after recovery from CABG. Therefore, we performed off-pump CABG via left thoracotomy using a saphenous vein Y-graft. Proximal anastomosis was placed in the descending aorta, and the distal anastomoses were completed with a stabilizer and an apical retraction device. Postoperative angiograms showed both grafts were patent and had suitable layout for subsequent esophageal surgery. In conclusion, off-pump CABG via left thoracotomy is an appropriate option for myocardial revascularization, if median sternotomy is contraindicated.
　Jpn. J. Cardiovasc. Surg. 31：408-410 (2002)

A Case of Double Valve Replacement 22 Years after the First Aortic Valve Replacement in a Patient with Swyer-James Syndrome 　　H. Shikata, et al.…411

A Case of Double Valve Replacement 22 Years after the First Aortic Valve Replacement in a Patient with Swyer-James Syndrome

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

Hiroo Shikata*^,** Shigeru Sakamoto* Yasuhiro Nagayoshi*

Hisateru Nishizawa* Michitaka Kouno* Katsunori Takeuchi*

Junichi Matsubara*

A 53-year-old woman was admitted because of cardiac failure caused by mitral valve stenosis and regurgitation. She had been treated by an aortic valve replacement with a Björk-Shiley convexo-concave valve (21mm) 22 years previously in our institute. Her clinical symptoms and the histological findings of the lung specimen from the operation led to a diagnosis of Swyer-James syndrome. The diagnosis was confirmed by pulmonary blood flow scintigraphy on the present admission. With her informed consent, we treated her cardiac disease by mitral valve replacement and a second aortic valve replacement was carried out because of the structural brittleness of the Björk-Shiley convexo-concave valve. She was discharged from our institute after the operation without any complications.
　Jpn. J. Cardiovasc. Surg. 31：411-413 (2002)

Surgical Treatment of Ebstein Anomaly in Two Adult Cases: Limitations and Difficulties of Carpentier's Procedure 　　T. Yamakawa, et al.…414

Surgical Treatment of Ebstein Anomaly in Two Adult Cases: Limitations and Difficulties of Carpentier's Procedure

(Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan and Department of Surgery, Hokkaido Kin-I-Kyou Central Hospital, Sapporo, Japan and Department of Surgery, Hokkaido Kin-I-Kyou Central Hospital*, Sapporo, Japan)

Tomoji Yamakawa* Toshihumi Murashita Jun-ichi Oka

Takehiro Kubota Michiaki Imamura Norihiko Shiiya

Keishu Yasuda

In repair of the tricuspid valve (TV) due to Ebstein's anomaly, mobilization of the anterior leaflet associated with longitudinal right ventricle plication (Carpentier's procedure) has provided good results in both short- and long-term follow-up. However, if the anterior leaflet is small or severely deformed, such repair may be ineffective. We report two cases of Ebstein's anomaly (63 and 53 years old) with deformed anterior leaflets of the TV in whom Carpentier's procedure was not feasible. In one patient, the anterior leaflets were broadly plastered on the right ventricle and Carpentier's procedure was tried. However, the repair was converted to valve replacement because of significant residual regurgitation. The other patient had a cleft in the anterior leaflet, therefore Carpentier's procedure was not suitable. The repair restructured the valve mechanism below the true annulus by using the most mobile leaflets for valve closure (modified Hetzer's procedure). This method of repair could be an alternative method to repair of the TV in Ebstein's anomaly, particularly when the anterior leaflet is deformed.
　Jpn. J. Cardiovasc. Surg. 31: 414-417 (2002)

Investigation of Mitral Valve Replacement in a Patient with Mitral Valve Stenosis Who Complicated with Myelodysplastic Syndrome and Left Atrial Thrombosis 　　S. Yamashiro, et al.…418

Investigation of Mitral Valve Replacement in a Patient with Mitral Valve Stenosis Who Complicated with Myelodysplastic Syndrome and Left Atrial Thrombosis

(Second Department of Surgery, School of Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan)

Satoshi Yamashiro Yukio Kuniyoshi Kazufumi Miyagi

Mitsuyoshi Shimoji Toru Uezu Katsuya Arakaki

Katsuto Mabuni Shigenobu Senaha Kageharu Koja

Patients with myelodysplastic syndrome (MDS) most commonly have refractory anemia accompanied by various degrees of granulocytopenia and thrombocytopenia. At the time of cardiac surgery, both major infections and bleeding are severe complications in patients with pancytopenia due to MDS. However, there were very few patients with MDS who had undergone open-heart surgery. We reported a case of mitral valve replacement in a patient with MDS. A 68-year-old man with valvular heart disease and MDS, with a platelet count of 1.9×10⁴/mm³, underwent successful mitral valve replacement. The mitral valve was replaced by an SJM25A prosthesis after resection of left atrial thrombosis using cardiopulmonary bypass. Platelets were transfused after the bypass. Perioperative hemorrhage was moderate and postoperative course was uneventful. We evaluated platelet function by Sonoclot coagulation and a platelet function analyzer. We did not need a large amount of transfusion of red blood cells and platelets, and prevented major bleeding and severe wound infections in the acute postoperative state.
　Jpn. J. Cardiovasc. Surg. 31：418-421（2002)

A Successful Combined Aortic and Mitral Valve Replacement after Renal Transplantation 　　M. Mohri, et al.…422

A Successful Combined Aortic and Mitral Valve Replacement after Renal Transplantation

(Department of Cardiovascular Surgery, Heart Center Sakakibara Hospital, Okayama, Japan and Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan)

Makoto Mohri* Takato Hata Yoshimasa Tsushima

Mitsuaki Matsumoto Hidenori Yoshitaka Sohei Hamanaka

A combined aortic and mitral valve replacement was performed in a 50-year-old man who had undergone living-related renal transplantation one year previously. The oral administration of tacrolimus was continued perioperatively while monitoring blood tacrolimus level. The postoperative administration of human atrial natriuretic peptide (hANP) was effective to maintain urine output was performed in addition to frosemide, mannitol, dopamin and prostaglandin E1 infusions. He was discharged on the 37th postoperative day without rejection, infection or renal dysfunction. This is the first report in Japan describing successful combined aortic and mitral valve replacement after renal transplantation.
　Jpn. J. Cardiovasc. Surg. 31：422-424 (2002)

Emergency Double Valve Replacement for Acute Mitral Regurgitation due to Ruptured Chordae Tendineae Associated with Congenital Bicuspid Aortic Valve Insufficiency 　　M. Oshiumi, et al.…425

Emergency Double Valve Replacement for Acute Mitral Regurgitation due to Ruptured Chordae Tendineae Associated with Congenital Bicuspid Aortic Valve Insufficiency

(Department of Cardiac Surgery, Jikei University Kashiwa Hospital, Chiba, Japan, Department of Cardiac Surgery, Jikei University School of Medicine*, Tokyo, Japan and Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center**, Saitama, Japan)

Motohiro Oshiumi Kiyozou Morita* Kazuhiro Hashimoto**

Asatoshi Mizuno Hiromitsu Takakura** Hirokuni Naganuma

We present a rare case of mitral valve prolapse associated with congenital bicuspid aortic valve, followed by abrupt left chordae tendineae rupture resulting in severe left heart failure and cardiac arrested. The patient, a 43-year-old man who had been admitted because of sudden orthopnea suffered cardiac arrest on arrival in the emergency unit. After successful cardiopulmonary resuscitation, emergency double-valve replacement (SJM25mm for the aortic valve and Carbomedics 31mm for the mitral valve) was performed; his postoperative course was uneventful. Concerning the pathogenesis of the acute rupture of the chordae tendineae in this patient with no evidence of infective endocarditis, it was likely that chronic and progressive left ventricular volume overload due to aortic regurgitation caused by congenital bicuspid aortic valve was the causative factor of abrupt rupture of the chordae tendineae during the course of mild mitral valve prolapse.
　Jpn. J. Cardiovasc. Surg. 31: 425-427 (2002)

Traumatic Ulnar Artery Aneurysm: A Case Report 　　T. Hanada, et al.…428

Traumatic Ulnar Artery Aneurysm: A Case Report

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

Tomoki Hanada Masanobu Yamauchi Tetsuya Higami

A 42-year-old man noted a left hypothenar mass about one week after hitting the palm of his left hand. Although he did not seek treatment, numbness and cyanosis of the left 2nd, 3rd, 4th, and 5th digits appeared suddenly about one year later. A computed tomography scan revealed an ulnar artery aneurysm with a mural thrombus, with a maximal diameter of 20 mm, at the site where the ulnar artery passed near the hamate bone. The aneurysm was excised, and the ulnar artery was reconstructed with direct end-to-end anastomosis. Traumatic ulnar artery aneurysm is commonly seen in workers who use the hypothenar eminence of their hands as a hammer, and is usually accompanied by finger ischemia.
　Jpn. J. Cardiovasc. Surg. 31：428-430 (2002)