Japanese Journal of Cardiovascular Surgery Vol.32, No.5

Originals

  • The Elephant Trunk Procedure for Aortic Dissection 　　N. Koizumi, et al.…267
    The Elephant Trunk Procedure for Aortic Dissection

    (Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan, Department of Surgery II, Tokyo Medical University*, Tokyo, Japan and Department of Thoracic Surgery, Fujita Health University School of Medicine**, Toyoake, Japan)
    Nobusato Koizumi* Motomi Ando** Yuji Hanafusa
    Osamu Tagusari Hitoshi Ogino Soichiro Kitamura
    The elephant trunk procedure is used to close the false lumen of the distal aorta in the surgical treatment for aortic dissection. We examined the state of the false lumen thrombus and measured the diameter of the aortic dissection, using postoperative digital subtraction angiography and computed tomographic scanning. We performed the elephant trunk procedure in 24 cases in the period, between January 1995 to December 1999. Total aortic arch replacement was performed in Stanford type A dissection, and descending aorta replacement was performed in Stanford type B dissection. In all patients, thrombotic closure around the elephant trunk graft was confirmed. Thromboexclusion of the false lumen of the descending aorta was observed in 18 cases (75.0%). The secondary operation may be unnecessary, because there was a tendency towards reduction of the diameter of dissecting aorta. These data revealed that this procedure was effective. In 6 cases (25.0%), residual dissection was recognized in the thoracoabdominal aorta, but there was no case of expansion requiring further operation. Nevertheless, careful follow-up is necessary, because aneurysms could expand in the future.
    　Jpn. J. Cardiovasc. Surg. 32: 267 -271 (2003)
  • Clinical Result of Consecutive 65 Cases of Minimally Invasive Direct Coronary Artery Bypass Grafting 　　T. Suzuki, et al.…272
    Clinical Result of Consecutive 65 Cases of Minimally Invasive Direct Coronary Artery Bypass Grafting

    (Department of Cardiovascular Surgery, Kochi Municipal Hospital, Kochi, Japan)
    Tomoaki Suzuki Manabu Okabe Mitsuteru Handa
    Atsushi Takamori Fuyuhiko Yasuda Yuo Kanamori
    Minimally invasive direct coronary artery bypass grafting (MIDCAB) has been performed in some institutions and mid-term results have been reported. However, because of its technical difficulty, the procedure has not been gaining acceptance among cardiovascular surgeons. We report the clinical results of our MIDCAB series and describe the effect and role of the MIDCAB in the therapy of ischemic heart disease. From May 1999 through May 2002, 65 patients (age 29 to 90 years) underwent MIDCAB via a small left thoracotomy. Postoperative angiography was performed before discharge in all patients. No conversions to sternotomy were necessary. There were no operative, hospital or mid-term mortalities, nor were these any major complications, including myocardial infarction, stroke, respiratory failure, and other organ failure. Wound infection occurred in 1 patient. No graft occlusion was seen. Graft stenosis was seen in only 1 patient. The graft patency rate was 98.5% (66/67). Postoperative cardiac events included 2 incidents of angina, and 4 of atrial fibrillation. There were no incidents of congestive heart failure. MIDCAB is a safe and less-invasive operation. According to our clinical results, MIDCAB is an alternative to conventional coronary artery bypass grafting for selected patients, especially for those at high risk.
    　Jpn. J. Cardiovasc. Surg. 32: 272 -275 (2003)

Case Reports

  • A Case of Coronary Artery Bypass Grafting through the Left Thoracotomy after Substernal Gastric Interposition for Carcinoma of the Esophagus 　　Y. Kato, et al.…276
    A Case of Coronary Artery Bypass Grafting through the Left Thoracotomy after Substernal Gastric Interposition for Carcinoma of the Esophagus

    (Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan)
    Yasuyuki Kato Satoru Miyamoto Hirokazu Minamimura
    Takumi Ishikawa Tadahiro Murakami Hiroyuki Nishi
    Kensuke Ohue Yoshihiro Shimizu
    We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.
    　Jpn. J. Cardiovasc. Surg. 32: 276 -279 (2003)
  • False Aneurysm in the Right Groin due to Disruption of a Knitted Dacron Prosthesis 　　K. Ogata, et al.…280
    False Aneurysm in the Right Groin due to Disruption of a Knitted Dacron Prosthesis

    (Second Department of Surgery, University of Yamanashi Faculty of Medicine, Yamanashi, Japan)
    Koji Ogata Syunya Shindo Atsuo Kojima
    Masahiro Kobayashi Seiichiro Katahira Masatake Katsu
    Harunobu Matsumoto Tadao Ishimoto Yusuke Tada
    A 52-year-old man presented with a pulsatile mass in the right groin. He had undergone lumbar sympathectomy and aorto-right femoral artery bypass using an 8mm Microvel double velour graft, 14 years previously, for aortoiliac occlusive disease caused by thromboangiitis obliterans. Based on a clinical diagnosis of an anastomotic aneurysm, an operation was performed. When the aneurysm was incised, it was found that the anastomosis of the graft to the femoral artery was intact and that the graft itself had a defect, 3cm in size on the anterior wall, 1.5cm proximal to the distal anastomosis. The final diagnosis was a nonanastomotic false aneurysm due to prosthetic graft failure. The failed portion of the graft was resected, and a 10mm Hemashield Gold woven double velour graft was interposed between the old graft and the right femoral artery. Generally, arterial grafts below the groin are subject to high levels of mechanical stress, and graft failure is not uncommon. Vascular surgeons should keep in mind that graft failure is not rare in patients with long-standing prosthetic grafts.
    　Jpn. J. Cardiovasc. Surg. 32: 280 -284 (2003)
  • Perigraft Seroma after Endovascular Repair of the Abdominal Aortic Aneurysm 　　N. Toya, et al.…285
    Perigraft Seroma after Endovascular Repair of the Abdominal Aortic Aneurysm

    (Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan and Department of Surgery, The Albert Einstein College of Medicine*, New York, U.S.A.)
    Naoki Toya Takao Ohki* Makoto Sumi
    Hisano Toriumi Yuka Negishi
    A 75-year-old man underwent endovascular repair of the abdominal aortic aneurysm. The procedure was aorto-uni-femoral endograft and femorofemoral crossover bypass using PTFE graft. The postoperative course was satisfactory, but 4 years after operation, he was admitted complaining of abdominal fullness. CT scan showed significant increase of aneurysm diameter to 13cm without evidence of endoleak. Endograft replacement with a new Dacron graft was carried out. Intraoperative findings suggested perigraft seroma related to the use of PTFE, and there was no endoleak. The postoperative course was uneventful. Pathological finding of aneurysm showed a lack of hemocytes and thrombocytes.
    　Jpn. J. Cardiovasc. Surg. 32: 285 -287 (2003)
  • Successful Surgical Treatment of Thoracic Aortic Aneurysm in Two Patients with Old Cerebral Infarcts and Severely Stenotic Cerebral Vessels 　　T. Okano, et al.…288
    Successful Surgical Treatment of Thoracic Aortic Aneurysm in Two Patients with Old Cerebral Infarcts and Severely Stenotic Cerebral Vessels

    (Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan)
    Takahisa Okano Shinichi Satoh Keiichi Kanda
    Yasuyuki Shimada Hitoshi Yaku Nobuo Kitamura
    Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.
    　Jpn. J. Cardiovasc. Surg. 32: 288 -292 (2003)
  • A Case Report of Mitral Valve Replacement for the Patient with Severely Calcified Mitral Annulus after Long-Term Hemodialysis 　　K. Adachi, et al.…293
    A Case Report of Mitral Valve Replacement for the Patient with Severely Calcified Mitral Annulus after Long-Term Hemodialysis

    (Departments of Thoracic and Cardiovascular Surgery, Shingu General Medical Center*1, Wakayama, Japan, Department of Surgery, Departments of Thoracic and Cardiovascular Surgery, Toyooka Hospital*2, Hyogo, Japan, Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine*3, Mie, Japan, Department of Thoracic and Cardiovascular Surgery, Mie General Medical Center*4, Mie, Japan and Department of Surgery, Department of Thoracic and Cardiovascular Surgery, Kobe City General Hospital*5, Kobe, Japan)
    Katsutoshi Adachi*1,*2 Tomoaki Sato*2 Hironori Tenpaku*2
    Masaki Kajimoto*2 Shigeyuki Makino*3 Koji Hirano*3
    Jin Tanaka*4 Yukikatsu Okada*5
    A 53-year-old woman underwent mitral valve replacement for congestive heart failure due to mitral stenosis and regurgitation. She had been receiving hemodialysis because of diabetic nephropathy since 1993, and had had congestive heart failure since 1999. Echocardiography demonstrated mitral stenosis (MVA; 1.10cm2) and regurgitation with a severely calcified mitral annulus. Annular calcification extended to the posterior wall of the left ventricle and the base of bilateral papillary muscles. After removing all calcium from the mitral annulus to the base of the papillary muscle, the left ventricular posterior wall and mitral annulus were reconstructed by glutaraldehyde-preserved autologous pericardium. Then, a Carbo-Medics mechanical valve was placed at the mitral annulus using everting mattress sutures. Although her hemodynamics were stable, bacteremia and multi-organ failure developed 3 months after surgery and she died. Autopsy showed that the reconstructed left ventricular posterior wall and mitral annulus using glutaraldehyde preserved autologous pericardium were in excellent condition without any thrombus. No dehiscence was found at the suture line of the mechanical valve. Mitral annulus reconstruction with glutaraldehyde preserved autologous pericardium is thought to be effective for patients with calcified mitral annulus who require mitral valve surgery.
    　Jpn. J. Cardiovasc. Surg. 32: 293 -296 (2003)
  • Autologous Blood Donation and Open Heart Surgery in a Patient with Ischemic Heart Disease and Type I CD36 Deficiency 　　S. Okumura, et al.…297
    Autologous Blood Donation and Open Heart Surgery in a Patient with Ischemic Heart Disease and Type I CD36 Deficiency

    (Department of Cardiovascular Surgery, Shiga National Hospital, Yokaichi, Japan)
    Satoru Okumura Jun Okawara Yoshinobu Maeda
    In patients with type I CD36 deficiency, immunization with CD36 antigen (Naka) through pregnancy or transfusion, could produce anti-CD36 antibody (anti-Naka), and potentially lead to platelet transfusion refractoriness or posttransfusion purpura. We report a 72-year-old woman who had no history of pregnancy or previous blood transfusions. She had been treated medically for hypertension and heart failure since the age of 65 years. Type I CD36 deficiency was also diagnosed based on the findings of 123I-β-methyl-iodophenyl pentadecanoic acid cardiac scintigraphy. At 72 years of age, she suffered acute thromboembolism in the left external iliac artery. The thrombus was removed and a left external iliac artery to left superficial femoral artery bypass was performed without any blood transfusion. Echocardiography, left ventriculography and coronary angiography showed left ventricular aneurysm and coronary artery disease. Resection of the left ventricular aneurysm and coronary artery bypass grafting were performed without donor blood transfusion. Autotransfusion by autologous blood donation and intraoperative autologous blood transfusion was used to avoid sensitization by the CD36 antigen through donor blood transfusion. Autotransfusion should be performed to avoid complications associated with donor blood transfusion particularly in patients with type I CD36 deficiency.
    　Jpn. J. Cardiovasc. Surg. 32: 297 -299 (2003)
  • A Case Report of Surgical Treatment for Infectious Endocarditis with Ventricular Septal Defect and Double-Chambered Right Ventricle 　　R. Suzuki, et al.…300
    A Case Report of Surgical Treatment for Infectious Endocarditis with Ventricular Septal Defect and Double-Chambered Right Ventricle

    (The Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan)
    Ryusuke Suzuki Masamichi Nakajima Toshiaki Watanabe
    Ken Okamoto Akiyuki Takahashi
    We report a successfully treated case of infectious endocarditis with ventricular septal defect (VSD) and double-chambered right ventricle. A 41-year-old man complained of dyspnea. Echocardiography showed his tricuspid valve, aortic valve, and pulmonary valve had vegetation and severe regurgitation. He received treatment with antibiotics but it was not effective. He underwent TVR, AVR, pulmonary valve resection, VSD patch closure and RV abnormal muscle resection. Pathological findings of resected valves showed infectious endocarditis. He recovered uneventfully and resumed his original social activities.
    　Jpn. J. Cardiovasc. Surg. 32: 300 -303 (2003)
  • A Case of Combined Operation of Abdominal Aortic Aneurysm and Invasive Carcinoma of the Bladder 　　H. Suzuki, et al.…304
    A Case of Combined Operation of Abdominal Aortic Aneurysm and Invasive Carcinoma of the Bladder

    (Department of Cardiovascular Surgery, Mie General Medical Center, Yokkaichi Japan and Department of Thoracic Surgery, Anjo Kosei Hospital*, Anjo, Japan)
    Hitoshi Suzuki* Jin Tanaka Tetsuo Mizutani
    The patient was a 75-year-old man who was referred due to hematuria. CT revealed bladder carcinoma 8cm in length, a 5-cm aneurysm of the abdominal aorta and a3-cm aneurysm of the left common iliac artery. He was referred to our hospital for the treatment of bladder carcinoma and aneurysms. We simultaneously performed Y graft replacement, radical cystectomy and bilateral cutaneous ureterostomy. His postoperative course was uneventful, without any prosthetic infection.
    　Jpn. J. Cardiovasc. Surg. 32: 304 -306 (2003)
  • A Case of Aortic Replacement for a Patient with Bilateral Internal Carotid Stenoses 　　A. Yamazaki, et al.…307
    A Case of Aortic Replacement for a Patient with Bilateral Internal Carotid Stenoses

    (Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women' s Medical University, Tokyo, Japan)
    Akira Yamazaki Shigeyuki Aomi Masaki Nonoyama
    Hideyuki Tomioka Kenji Yamazaki Akihiko Kawai
    Hiroshi Nishida Masahiro Endo Hiromi Kurosawa
    A 71-year-old man was given a diagnosis of saccular aneurysm of the aortic arch (maximum 48mm in diameter) at the age of 68. When he was 69 years old, he began to take steroids for autoimmune hepatitis (AIH). The following year, the aneurysm was enlarged to 52mm. Further examinations showed the aneurysm to extend to the ostium of the left subclavian artery. Since he had transient ischemic attacks, ultrasonography of the carotid arteries was performed. Bilateral internal carotid stenoses were detected, however, cold Xe CT showed an almost normal pattern of cerebral blood flow. We decided that operation was feasible using retrograde cerebral perfusion (RCP). Liver dysfunction due to AIH improved, and his steroid dosage was tapered. Using RCP, the no-touch technique and the elephant trunk procedure, he underwent the replacement of ascending aorta and aortic arch and was discharged without major complications. RCP and the no-touch technique might enable safer operations on patients with carotid stenoses.
    　Jpn. J. Cardiovasc. Surg. 32: 307 -310 (2003)
  • A Case of Endovascular Stent Graft Repair for Thoracic Descending Aortic Aneurysm with Porcelain Aorta 　　T. Mizumoto, et al.…311
    A Case of Endovascular Stent Graft Repair for Thoracic Descending Aortic Aneurysm with Porcelain Aorta

    (Department of Thoracic Surgery, Anjo Kosei Hospital, Anjo, Japan, Departments of Thoracic and Cardiovascular Surgery, Shingu Municipal Medical Center*, Wakayama, Japan, Department of Radiology, Mie University School of Medicine**, Tsu, Japan and Department of Radiology, Matsuzaka Central Hospital***, Matsuzaka, Japan)
    Toru Mizumoto* Iwao Hioki Toshihiko Kinoshita
    Hideki Fujii Noriyuki Kato** Tadanori Hirano***
    A 50-year-old man was admitted with a fusiform descending thoracic aortic aneurysm measuring 60mm. Chest CT scan revealed porcelain aorta from the aortic arch to the abdominal aorta. Severe calcification found on the descending aortic wall was considered to entail greater risk for conventional aortic repair and reconstruction of intercostal arteries. Therefore endovascular stent grafting was planned. The stent graft was deployed from near the origin of the left subclavian artery to the 10th thoracic vertebral level. Neither paraplegia nor other complication occurred. Endovascular stent grafting may be a safe and effective method for descending thoracic aneurysms with severely calcified aorta.
    　Jpn. J. Cardiovasc. Surg. 32: 311 -313 (2003)
  • A Case of Persistent Ductus Arteriosus in an Elderly Patient after Artificial Right Pneumothorax 　　S. Okumura, et al.…314
    A Case of Persistent Ductus Arteriosus in an Elderly Patient after Artificial Right Pneumothorax

    (Department of Cardiovascular Surgery, Shiga National Hospital, Yokaichi, Japan)
    Satoru Okumura Jun Okawara Yoshinobu Maeda
    The patient was a 75-year-old woman, who had been treated for tuberculosis by artificial right pneumothorax at the age of 25. Although a cardiac murmur had been pointed out in her infancy, no treatment had been recommended because she had no symptoms. Effort dyspnea augmented along with her aging by degrees. She began to need oxygen therapy at the age of 75. She had her calcified ductus arteriosus. The systemic to pulmonary blood flow ratio (Qp/Qs) was 1.89. We diagnosed that pulmonary dysfunction after artificial right pneumothorax and pulmonary hypertension caused by persistent ductus arteriosus were the cause of her symptoms. After median sternotomy we closed the persistent ductus arteriosus using a patch through the pulmonary artery under cardiopulmonary bypass. Although she needed respiratory management with a ventilator for 2 days and oxygen therapy for 4 weeks, she has been doing well afterwards. We think that we should close persistent ductus arteriosus even in the elderly.
    　Jpn. J. Cardiovasc. Surg. 32: 314 -317 (2003)
  • Redo CABG Using Lateral Minimally Invasive Direct Coronary Artery Bypass Technique ―Selection of Grafts, Bypass Inflow and Bypass Routes― 　　Y. Hayata, et al.…318
    Redo CABG Using Lateral Minimally Invasive Direct Coronary Artery Bypass Technique -Selection of Grafts, Bypass Inflow and Bypass Routes-

    (Department of Surgery III, Nara Medical University, Kashihara, Japan)
    Yoshihiro Hayata Tetsuji Kawata Hidehito Sakaguchi
    Nobuoki Tabayashi Yoshiro Yoshikawa Shigeo Nagasaka
    Takashi Ueda Takehisa Abe Kozo Morita
    Shigeki Taniguchi
    We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.
    　Jpn. J. Cardiovasc. Surg. 32: 318 -321 (2003)
  • Y-graft Replacement for Ruptured of Abdominal Aortic Aneurysm in an Elderly Patient 　　T. Ogino, et al.…322
    Y-graft Replacement for Ruptured of Abdominal Aortic Aneurysm in an Elderly Patient

    (Division of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Maebashi, Japan and Second Department of Surgery, Gunma University School of Medicine*, Maebashi, Japan)
    Takashi Ogino Tatsuo Kaneko Yasushi Satoh
    Masahiko Ezure Yutaka Hasegawa Hirotaka Inaba
    Toshiharu Yamagishi Shigeru Ohki Yasuo Morishita*
    Y-graft replacement was successfully performed in a patient aged 93years with ruptured infrarenal abdominal aortic aneurysm. The patient was in shock on arrival and underwent an emergency operation with the administration of cathecholamines. The ruptured infrarenal abdominal aortic aneurysm with a large hematoma, which was located in the area of the left common iliac artery, was 10cm in the maximum diameter. The bilateral common iliac arteries were strongly calcified and occluded. The distal end of the graft was anastomosed to the external iliac artery. The patient's postoperative course was uneventful.
    　Jpn. J. Cardiovasc. Surg. 32: 322 -324 (2003)