Japanese Journal of Cardiovascular Surgery Vol.32, No.3

Originals

  • Fibrinogen Level and Its Influence on Cardiopulmonary Bypass in Surgery for Aortic Dissection 　　S. Tsukamoto, et a…l21
    Fibrinogen Level and Its Influence on Cardiopulmonary Bypass in Surgery for Aortic Dissection

    (Department of Cardiovascular Surgery, National Hospital Tokyo Disaster Medical Center, Tokyo, Japan and The Second Department of Surgery, Nihon University School of Medicine*, Tokyo, Japan)
    Saeki Tsukamoto Shoji Shindo Masahiro Obana
    Kenji Akiyama* Motomi Shiono* Nanao Negishi*
    For the purpose of reducing blood loss and blood transfusion, 100 cases of acute aortic dissection treated at this department were studied, focusing on surgery for aortic dissection and coagulation factors, fibrinogen in particular. In cases of aortic dissection, fibrinogen decreased at the acute stage, and showed concentrations significantly lower in Stanford Type A than in Stanford Type B, in extensive dissection (DeBakey Type I or Type III retrograde dissection) than in limited dissection (DeBakey Type II), and in open false lumen type than in closed false lumen type. In the assessment of 34 cases of acute Stanford Type A aortic dissection operated on within 24h of onset, it was found that a marked prolongation of activated clotting time (ACTｳ1,000s) during cardiopulmonary bypass causes an increase in blood transfusion. When ACT was maintained for 400s or longer, to inhibit the marked prolongation of ACT, by changing at any time the dose of heparin during cardiopulmonary bypass by 50 -250units/kg on the basis of the preoperative fibrinogen level, instead of fixing it at 300units/kg, ACT decreased significantly, and was controlled at appropriate levels despite the low concentration of fibrinogen. As fibrinogen can be measured in the hospital, and the result obtained in a short time, it is considered to play an important role in controlling ACT to determine the dose of heparin based on its concentration.
    　Jpn. J. Cardiovasc. Surg. 32：121 -125 (2003)
  • Usefulness of Preoperative Coronary Angiography and Brain Computed Tomography in Cases of Coronary Artery Disease and Cerebrovascular Disease Undergoing Revascularization for Arteriosclerosis Obliterans 　　T. Sakurada and Y. Shibata…126
    Usefulness of Preoperative Coronary Angiography and Brain Computed Tomography in Cases of Coronary Artery Disease and Cerebrovascular Disease Undergoing Revascularization for Arteriosclerosis Obliterans

    (Department of Cardiovascular Surgery, Southern Tohoku Fukushima Hospital, Fukushima, Japan)
    Tall Sakurada Yoshiki Shibata
    Coronary angiography and brain computed tomography were preoperatively performed to evaluate the clinical condition of coronary artery disease and cerebrovascular disease in 101 patients (mean age, 68.4 years) with revascularization for arteriosclerosis obliterans. Eighty patients had hypertension, 12 had diabetes, and 26 had hyperlipidemia. Seventy-one patients (70.3%) had coronary stenosis. Significant stenoses in major coronary artery branches were confirmed in 35 patients, including 13 patients with old myocardial infarction. Coronary artery bypass grafting and percutaneous coronary angioplasty were performed in 2 and 7 patients with critical stenosis, respectively. Of 57 patients, who underwent brain computed tomography, abnormalities were found in 52 patients (91.2%), including cortical infarction in 9, lacunar infarction in 35, and leukoaraiosis in 27 patients. During the follow-up period 13 patients died (including 3 cases of myocardial infarction and 3 cases of stroke). Actuarial survival rate at 5 years was 80.4%. The influence of ischemic heart disease and cerebrovascular disease on early and late mortality after surgical reconstruction for peripheral occlusive vascular disease is significant. Using visual diagnostic techniques, such as coronary angiography and brain computed tomography, long term survivor should be closely observed for multiple arteriosclerotic vascular diseases.
    　Jpn. J. Cardiovasc. Surg. 32：126 -131 (2003)

Case Reports

  • A Case of Inflammatory Abdominal Aortic Aneurysm Whose Persistent Postoperative High Fever Was Successfully Treated by Steroid 　　N. Uchida and M. Yamazaki…132
    A Case of Inflammatory Abdominal Aortic Aneurysm Whose Persistent Postoperative High Fever Was Successfully Treated by Steroid

    (Department of Surgery, Mito Red Cross Hospital, Mito, Japan and Department of Cardiovascular Surgery, Ashikaga Red Cross Hospital*, Tochigi, Japan)
    Norio Uchida Masataka Yamazaki*
    The indications of steroid therapy for inflammatory abdominal aortic aneurysm (IAAA) is controversial. We here report a rare case whose persistent postoperative high fever and duodenal obstruction due to adhesion to the residual aortic wall were successfully treated by steroid. A 73-year-old man was referred to our hospital because of abdominal pain and a pulsating mass in his umbilical region. CT scan showed a remarkably dilated infrarenal abdominal aorta (10cm in diameter) with a mantle sign. Preoperatively C-reactive protein (CRP) was high, however temperature was normal. We replaced the aneurysm with a bifurcated prosthetic graft (18×9mm collagen impregnated knitted Dacron) by laparotomy on April 10, 2001. The aneurysm showed a thick and fibrous surface tightly adhering to the jejunum, sigmoid colon and ureters. We tried to minimize surgical injury to perianeurysmal fibrotic tissue. However the right ureter was injured and repaired using a double-J catheter. Histopathological examination revealed lymphoplasmocystic infiltration in the wall of the aorta, which was compatible with IAAA. From the 10th postoperative day high fever (38 to 39℃) persisted and CT revealed perigraft seroma with air density. Graft infection was suspected and the perigraft fluid was drained by puncture. However cultures of the serous fluid was negative. Moreover, approximately 1,500ml gastric juice was drained per day via a nasogastric tube. Therefore we suspected postoperative inflammatory reactions to the impregnated Dacron graft and/or inflammation of the residual aortic wall. This patient was given 20mg prednisolone intravenously 18 days after the operation and the dose of steroid was then tapered. This therapy had an obvious effect on the recovery of the general condition. Body temperature and CRP was normal when he was discharged 46 days after surgery. The patient had no complaints and the thickness of the residual aortic wall around the graft was found to have decreased one year after the operation on follow up CT.
    　Jpn. J. Cardiovasc. Surg. 32：132 -136 (2003)
  • Successful Surgical Management of an Aortic Arch Aneurysm with an Aorto-Pulmonary Artery Fistula 　　K. Suzuki, et al.…137
    Successful Surgical Management of an Aortic Arch Aneurysm with an Aorto-Pulmonary Artery Fistula

    (First Department of Surgery, Yamaguchi University School of Medicine, Ube, Japan and Miyamoto Clinic*, Kudamatsu, Japan)
    Kazuhiro Suzuki Kimikazu Hamano Sayaka Hanada
    Masanori Hayashi Bunngo Shirasawa Hiroshi Itou
    Akihito Mikamo Masaki Miyamoto*
    A 72-year-old woman had undergone resection and graft replacement of the proximal ascending aorta for a DeBakey type II aortic dissection. She presented again 7 years later with progressive dyspnea and a cough. Computed tomography confirmed an aortic arch aneurysm and Doppler echocardiography demonstrated aortopulmonary shunting. Cardiac catheterization revealed a fistula between the aorta and pulmonary artery with a 54.3% left-to-right shunt and a Qp/Qs of 2.19. Operative repair was performed under profound hypothermic circulatory arrest with selective cerebral perfusion. The aortopulmonary artery fistula was closed from within the aneurysm using an equine pericardial patch and the transverse aortic arch was resected and replaced with a graft. The patient recovered uneventfully and was discharged on postoperative day 43.
    　Jpn. J. Cardiovasc. Surg. 32：137 -140 (2003)
  • Cryopreserved Aortic Homografts for the Treatment of Prosthetic Graft Infections Caused by MRSA―A Case Report― 　　K. Nagaya, et al.…141
    Cryopreserved Aortic Homografts for the Treatment of Prosthetic Graft Infections Caused by MRSA - A Case Report -

    (Department of Cardiovascular Surgery, Tohoku University, Sendai, Japan)
    Koichi Nagaya Koichi Tabayashi Atushi Iguchi
    Hiroji Akimoto Yusuke Tsuru
    A 70-year-old man had undergone prosthetic graft replacement for aneurysm of the descending aorta. Postoperatively he suffered methicillin-resistant Staphylococcus aureus infection. Infection was controlled by antibiotics, and he was followed up in the outpatient clinic. However, he was readmitted due to high fever on the 192nd postoperative day. CT scan revealed abscess formation around the prosthetic graft. The wound was re-explored, and drainage, irrigation and packing with sponges soaked with povidoneiodine solution was performed for 3 days. After that, the prosthetic graft was replaced with a cryopreserved aortic homograft. The postoperative course was uneventful, and he showed no signs of recurrent infection for over 14 months.
    　Jpn. J. Cardiovasc. Surg. 32：141 -144（2003)
  • A Case of Chronic Contained Rupture of an Abdominal Aortic Aneurysm 　　H. Osawa, et al.…145
    A Case of Chronic Contained Rupture of an Abdominal Aortic Aneurysm

    (Department of Thoracic Surgery, Sapporo City General Hospital, Sapporo, Japan)
    Hisayoshi Osawa Satoru Sugimoto Kouji Maekawa
    Noriyasu Watanabe Toshiaki Tanaka
    A 72-year-old man was referred to our hospital because of lumbago and an abdominal aortic aneurysm (AAA). Computed tomography revealed the AAA to be 5cm in diameter with a retroperitoneal hematoma. A diagnosis of chronic contained rupture of an AAA was made, and an operation was performed. At laparotomy, a punched-out defect (10 X 20mm) that was thought to connect the thrombosed aneurysm to an organized retroperitoneal hematoma was discovered on the right side of the aorta. The aneurysm was replaced with a Y-shaped prosthetic graft. The patient's postoperative course was uneventful. This case of chronic contained rupture of an AAA was distinctly different from cases of acute rupture. Although patients with chronic contained rupture of an AAA are hemodynamically stable, such cases should be assessed and treated as quickly as possible because of the risk of re-rupture.
    　Jpn. J. Cardiovasc. Surg. 32：145 -147 (2003)
  • A Case of Extensive Cerebral Infarction Associated with Acute Aortic Dissection Responding to External Decompression and Mild Brain Hypothermia 　　M. Noguchi, et al.…148
    A Case of Extensive Cerebral Infarction Associated with Acute Aortic Dissection Responding to External Decompression and Mild Brain Hypothermia

    (Department of Cardiovascular Surgery, Sasebo Chuo Hospital, Sasebo, Japan)
    Manabu Noguchi Ryuuichiro Shibata Miyoko Iwamatsu
    A 56-year-old Japanese woman underwent hemi-arch replacement with selective cerebral perfusion for acute aortic dissection of DeBakey type I. A postoperative computed tomographic scan of the brain showed extensive infarction of the right hemisphere, a midline shift, and right uncal herniation. The patient received right fronto-temporo-parietal craniectomy and external decompression followed by mild brain hypothermia, targeting a rectal temperature of 34℃. Despite residual left hemiparesis, she became alert and successfully recovered. She was discharged 147 days after the operation. We conclude that external decompression with mild brain hypothermia was therapeutically useful, with no major complications, for the treatment of extensive cerebral infarction associated with acute aortic dissection.
    　Jpn. J. Cardiovasc. Surg. 32：148 -151 (2003)
  • Serious Interaction between Miconazole and Warfarin―A Case Report― 　　S. Fukuda, et al.…152
    Serious Interaction between Miconazole and Warfarin - A Case Report -

    (Department of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan)
    Sachito Fukuda Kazuhiro Naito Ikutaro Kigawa
    The patient was placed on anticoagulant therapy with warfarin after aortic valve replacement. Although it was initially possible to stabilize the international normalized ratio (INR＝2.90), the prothrombin time was significantly prolonged (INR＝31.39) after intravenous infusion of miconazole for 9 days at a dose of 200mg/day to treat lichen planus. Warfarin therapy was discontinued until the INR decreased to within the acceptable range, which required 14 days, and then warfarin was resumed. A stable INR value was achieved approximately 50 days later. Treatment with miconazole results in significant promotion of the anticoagulant effect of warfarin and a long period was required before normalization of the INR could be achieved in this patient. Accordingly, miconazole therapy should only be indicated in patients receiving treatment with warfarin when administration is essential. Caution should be employed when using this drug in combination with warfarin, and careful monitoring of the bleeding time is necessary.
    　Jpn. J. Cardiovasc. Surg. 32：152 -154　(2003)
  • A Case of Primary Angiosarcoma of the Heart 　　M. Okamoto, et al.…155
    A Case of Primary Angiosarcoma of the Heart

    (Department of Thoracic Surgery, Yokohama City Municipal Hospital, Yokohama, Japan)
    Masahiko Okamoto Hideshi Kurata Kouichirou Date
    We report a case of angiosarcoma of the right atrium manifesting as cardiac tamponade. The patient was a 34-year-old woman. Echocardiography, CT scans, MRI and coronary angiography revealed a tumor arising in the right atrium. Radical excision of the tumor with cardiopulmonary bypass was performed. The resected tumor measured 5×6×3 cm, and microscopic examination revealed angiosarcoma. Adjunctive radiation therapy was performed and she had high quality of her life for more than 2 years. However, she died of hemorrhage caused by liver metastasis of the tumor on the 29th postoperative month.
    　Jpn. J. Cardiovasc. Surg. 32：155 -157 (2003)
  • A Report of Successful Treatment of an Acute Aortic Dissection Associated with a Long-Term Steroid Therapy for Hypopituitarism 　　M. Tayama, et al.…158
    A Report of Successful Treatment of an Acute Aortic Dissection Associated with a Long-Term Steroid Therapy for Hypopituitarism

    (Department of Cardiovascular Surgery, Kawachi General Hospital, Higashi-Osaka, Japan)
    Masao Tayama Nobuo Sakagoshi Harumasa Yasuda
    A 58-year-old man was admitted with a diagnosis of an acute Stanford type A aortic dissection after 20-year-long steroid therapy for hypopituitarism. The graft replacement of the ascending aorta was performed as an emergency procedure under deep hypothermic selective cerebral perfusion. We administered 1,000 mg of methylprednisolone during cardiopulmonary bypass, injected 500 mg/day of hydrocortisone during postoperative day 1 to 4, and then administered orally 40 mg/day of hydrocortisone. Then 200μg of levothyroxine sodium was given orally from postoperative day 6. There are some reports about acute aortic dissection associated with long-term steroid therapy in SLE or aortitis syndrome, but reports involving hypopituitarism are very rare.
    　Jpn. J. Cardiovasc. Surg. 32：158 -160 (2003)
  • Aortic Sepsis with Aorto-Pulmonary Fistula Following Infective Endocarditis (IE) 　　H. Ozawa, et al.…161
    Aortic Sepsis with Aorto-Pulmonary Fistula Following Infective Endocarditis (IE)

    (Department of Cardiovascular Surgery, The Cardiovascular Center, Kyoto Katsura Hospital, Kyoto, Japan)
    Hideki Ozawa Hisao Kurihara Hiroshi Furukawa
    Masahiro Daimon Takahiro Katsumata
    A59-year-old man presented with sporadic febrile illness. Echocardiography showed multiple vegetations on the mitral valve. Blood culture yielded Viridans streptococci. Mitral valve replacement was performed, and a high dose of penicillin G sodium (24million U/day) was administrated for 4weeks postoperatively. On the 28th postoperative day, the patient developed severe back pain and bloody sputum. Chest CT showed a false aneurysm of the distal aortic arch (5.5cm). The patient was placed on cardiopulmonary bypass with the arterial return in the mid-aortic arch. The aneurysm was resected and replaced with a Dacron tube during deep hypothermic circulatory arrest. The aortic wall was interspersed with mobile nodules that appeared to be colonized. The aorto-pulmonary fistula was directly closed. The whole procedure was carried out through the 4th intercostal space. The tissue culture was negative but histopathology suggested a persistent inflammatory process. Excavating aortic sepsis may occur following active endocarditis. Even if cardiac infection is controlled, continuous search should be undertaken for possible dilatation in remote parts of the arterial system.
    　Jpn. J. Cardiovasc. Surg. 32：161 -163 (2003)
  • A Case of Combined Redo Off-Pump CABG with Right Gastroepiploic Artery and Abdominal Aortic Aneurysm Repair 　　Y. Nishimura, et al.…164
    A Case of Combined Redo Off-Pump CABG with Right Gastroepiploic Artery and Abdominal Aortic Aneurysm Repair

    (Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan)
    Yoshiharu Nishimura Yoshitaka Okamura Keiichi Fujiwara
    Hiroyoshi Sekii Shuji Yamamoto Takayuki Kuriyama
    Kouji Toguchi Kentarou Honda
    A case of combined redo off-pump CABG (OPCAB) with right gastroepiploic artery and abdominal aortic aneurysm repair is reported. A 71-year-old man with a previous history of CABG was admitted for the operation of recurrent angina pectoris and known abdominal aortic aneurysm. Preoperative coronary angiograms showed obstruction of LITA graft for LAD. The operative procedure consisted of redo OPCAB using right gastroepiploic artery as a transdiaphragmatic graft under left antero-lateral thoracotomy and graft replacement of abdominal aortic aneurysm under median laparotomy simultaneously. This strategy has the advantage of avoiding the continuity of median sternotomy and laparotomy and contributes to the minimally invasive procedure in the combined operation.
    　Jpn. J. Cardiovasc. Surg. 32：164 -167 (2003)
  • Total Aortic Arch Replacement with Open Stent-Grafting of Descending Thoracic Aorta for Chronic Type A Dissecting Aneurysm after Replacement of the Ascending Thoracic Aorta―A Case Report― 　　J. Akasaka, et al.…168
    Total Aortic Arch Replacement with Open Stent-Grafting of Descending Thoracic Aorta for Chronic Type A Dissecting Aneurysm after Replacement of the Ascending Thoracic Aorta - A Case Report -

    (Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan and Department of Cardiovascular Surgery, Mito National Hospital*, Mito, Japan)
    Junetsu Akasaka Yusuke Tsuru* Yoshio Nitta
    Goro Takahashi Koichi Tabayashi
    A 74-year-old woman underwent ascending aortic replacement due to acute type A dissection 2 years previously. She received total aortic arch replacement with open stent grafting of the descending thoracic aorta for enlargement of the residual aortic dissection in the aortic arch and descending thoracic aorta. Operative method and, intra- and post-operative protective method of spinal cord are reported and discussed.
    　Jpn. J. Cardiovasc. Surg. 32：168 -171 (2003)
  • A Case of Dacron Graft Aneurysm 18 Years after Left Subclavian Artery-Descending Aortic Bypass 　　M. Sakurai, et al.…172
    A Case of Dacron Graft Aneurysm 18 Years after Left Subclavian Artery-Descending Aortic Bypass

    (Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Japan)
    Manabu Sakurai Yoshiharu Takahara Kenji Mogi
    Dacron grafts have made great progress and the material has become almost perfect recently. However, we encountered a rare case of a late-graft complication. A34-year-old man was operated on for coarctation of the aorta in July 1982. Left subclavian artery-descending aortic bypass was performed using a Cooley double velour knitted graft. Eighteen years later, the patient was admitted to our hospital with an abnormal shadow in his chest X-ray. Angiography and computed tomography demonstrated a non-anastomotic aneurysm of the graft. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, reoperation with a woven Dacron graft was successfully performed. This case suggests that it is important to follow up patients with implanted Dacron arterial prostheses because of the potential for rupture.
    　Jpn. J. Cardiovasc. Surg. 32：172 -174 (2003)
  • Redo Coronary Revascularization Using Off-Pump Axillo-Coronary Artery Bypass Grafting 　　Y. Hachiro, et al.…175
    Redo Coronary Revascularization Using Off-Pump Axillo-Coronary Artery Bypass Grafting

    (Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kushiro Hospital, Kushiro, Japan and Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine*, Sapporo, Japan)
    Yoshikazu Hachiro Hideyuki Harada Toshio Baba
    Yukiko Honma Tomio Abe*
    We describe two patients who underwent repeat off-pump coronary revascularization by axillo-coronary artery bypass grafting. A 63-year-old man (case 1), who had undergone coronary artery bypass grafting (CABG) 13 years previously, was admitted to our hospital with exertional angina. The saphenous vein grafts (SVG) to the left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) all were occluded. The left internal thoracic artery (LITA) also was occluded because it had been injured. Because the patient declined to undergo a redo CABG, percutaneous transluminal coronary angioplasty (PTCA) to the LAD was attempted. However, coronary dissection occurred, and an emergency operation was performed. A 66-year-old man (case 2), who had undergone CABG 12 years previously, was admitted with unstable angina. The LITA to the LAD and the SVG to the RCA were occluded. The SVG to the Cx had 99% stenosis in its mid-portion and was the cause of the angina. PTCA and stenting of this SVG were performed. Two weeks later, an operation was done. In both patients, the left axillary artery was selected as the site of the proximal anastomosis. Both patients underwent off-pump bypass grafting to the LAD from the left axillary artery using a SVG. Both grafts were patent postoperatively. This approach resulted in early symptomatic improvement.
    　Jpn. J. Cardiovasc. Surg. 32：175 -177 (2003)