Japanese Journal of Cardiovascular Surgery Vol.33, No.1

Originals

Surgical Treatment of Active Infective Endocarditis: Determinants of Early Outcome 　　Y. Kamikubo, et al.…1

Surgical Treatment of Active Infective Endocarditis: Determinants of Early Outcome

(Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan)

Yasuhiro Kamikubo Toshifumi Murashita Hideyuki Kunishige

Norihiko Shiiya Keishu Yasuda

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). Streptococci (27.5%) and Staphylococci (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (p＝0.02), New York Heart Association class III or IV（p＝0.02), a preoperatively unidentified pathogen（p＝0.02）and concomitant operation for abscess and fistula (p＝0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospital mortality (p＝0.11). Multivariate analysis revealed that NYHA III -IV (p＝0.02, odds ratio＝18.1, 95% CI＝1.49 -220.1) and a preoperatively unidentified pathogen (p＝0.02, odds ratio＝7.45, 95% CI＝1.44 -38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.
　Jpn. J. Cardiovasc. Surg. 33: 1 -5 (2004)

Cardiac Output Measurement Using the Non-Invasive Cardiac Output (NICO) Monitor: A Comparative Study with the Standard Thermodilution Technique 　　C. Kimura, et al.…6

Cardiac Output Measurement Using the Non-Invasive Cardiac Output (NICO) Monitor: A Comparative Study with the Standard Thermodilution Technique

(Second Department of Surgery and Intensive Care Unit*, Gunma University, School of Medicine, Maebashi, Japan)

Chieri Kimura Fumio Kunimoto* Yasuo Morishita

The non-invasive cardiac output (NICO) monitor is a new device in order to measure cardiac output (CO). A rebreathing circuit is built in the NICO monitor and CO is calculated using the Fick CO₂ equation. We compared this technique with the standard thermodilution (TDCO) technique in patients with thoracic and abdominal surgery. Thirty-two paired data were obtained in 17 patients. Correlation between the two methods in patients with controlled mechanical ventilation (CMV) was fair, with a correlation coefficient of 0.85. However, the correlation coefficient of the two methods was 0.60 in spontaneous breathing patients. Bland-Altman analysis showed a bias of 0.24±0.68 (mean±2SD) in CMV patients and 1.44±1.28 in spontaneous breathing patients. The NICO value was inversely proportional to an end-tidal CO₂ difference (ΔETCO₂) between pre-rebreathing and post-rebreathing. The large bias in spontaneously breathing patients might be due to a small ΔETCO₂ in spontaneously breathing patients. The NICO monitor has a tendency to measure higher CO values in spontaneously breathing patients.
　Jpn. J. Cardiovasc. Surg. 33: 6 -8 (2004)

Optimal Anticoagulant Therapy after Mechanical Valve Replacement Reviewed in Terms of Activity of Coagulation and Fibrinolysis 　　N. Konagai, et al.…9

Optimal Anticoagulant Therapy after Mechanical Valve Replacement Reviewed in Terms of Activity of Coagulation and Fibrinolysis

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

Naoki Konagai Hiromi Yano Mitsunori Maeda

Tatsuhiko Kudo Shin Ishimaru*

Patients with mechanical valve prosthesis must receive long-term oral anticoagulant therapy, thus it is important to set the optimal international normalized ratio of prothrombin time (PT-INR) that effectively prevented thromboembolic complications without excessive bleeding. In this study, anticoagulant therapy was evaluated in terms of the activity of coagulation and fibrinolysis in 137 patients after isolated mechanical valve replacement. With a lower target range of 1.5 -2.0 for the PT-INR, thrombin antithrombin III complex (TAT) increased to more than 3.0 ng/ml in 30 cases, and the activity of coagulation appeared to increase due to insufficient anticoagulant therapy. After the target range was raised to 2.0 -2.5 in all cases, the PT-INR increased significantly from 1.63 to 2.25 (p<0.01) and TAT decreased significantly from 7.58 to 2.81 ng/ml (p<0.01). This showed that activity of coagulation and fibrinolysis was suppressed by high intensity anticoagulation. It is necessary to review the individual activity of coagulation and fibrinolysis to determine the intensity of anticoagulation. We recommend 2.0 -2.5 as the target range for the PT-INR.
　Jpn. J. Cardiovasc. Surg. 33: 9 -12 (2004)

Surgical Treatment for Aortic Surgery Using Antegrade Selective Cerebral Perfusion 　　Y. Maze, et al.…13

Surgical Treatment for Aortic Surgery Using Antegrade Selective Cerebral Perfusion

(Department of Thoracic Surgery, Yamada Red Cross Hospital, Mie, Japan)

Yasumi Maze Masaki Yada Yoshihiko Katayama

Sekira Shomura

Between October, 1992 and April, 2002, 40 patients underwent thoracic aorta surgery using antegrade selective cerebral perfusion. There were 29 men and 11 women, with a mean age of 67.2±8.1 years (range 45 to 79 years). Twenty-one patients were emergency (emergency group), and 19 were elective procedures (elective group). We compared preoperative, intraoperative and postoperative factors between the emergency group and elective group. In the emergency group, 15 patients underwent an ascending aortic replacement, 5 patients underwent a total arch replacement, 1 patient underwent a partial arch replacement. In the elective group, 2 patients underwent an ascending aortic replacement, 17 patients underwent a total arch replacement. Hospital mortality occurred in 5 patients in the emergency group (23.8%) and 1 in the elective group (5.2%). A permanent neurologic defect occurred in 1 patient in the emergency group (4.7%) and 1 in the elective group (5.2%). The results of surgical treatment of aortic surgery using antegrade selective cerebral perfusion were satisfactory.
　Jpn. J. Cardiovasc. Surg. 33: 13 -16 (2004)

Case Reports

A Case of Acute Type B Dissection with Limb Ischemia and Severely Compressed True Lumen Cured by Conservative Therapy 　　T. Sumiyoshi, et al.…17

A Case of Acute Type B Dissection with Limb Ischemia and Severely Compressed True Lumen Cured by Conservative Therapy

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

Tatsuaki Sumiyoshi Hiroshi Ishihara Naomichi Uchida

Sugumichi Ozawa

A 73-year-old man suddenly felt severe back pain. Computed tomography showed acute type B dissection. The false lumen existed from the distal arch to the right common femoral artery and was patent. The true lumen was severely compressed by the false lumen and his right leg was cold. In spite of limb ischemia, we started conservative therapy because he had severe airway stenosis due to obesity and obstructive sleep apnea syndrome (OSAS) and we thought surgical intervention very risky. We thought OSAS also involved a risk of high blood pressure and started continuous positive airway pressure. His blood pressure went down along with the improvement of respiratory conditon. After 12 days from the onset he evacuated bloody stool and gastrointestinal fiberscopy revealed giant gastric ulcer bleeding. Platelet counts and prothrombin time began to increase 2 days later. Computed tomography 14 days after onset showed a patent false lumen and severely compressed true lumen. Computed tomography 39 days after onset showed thrombosis of the false lumen and considerable dilatation of the true lumen. Hypercoagulability after bleeding from gastric ulcer and treatment of OSAS were important in this successful conservative therapy.
　Jpn. J. Cardiovasc. Surg. 33: 17 -21 (2004)

Late Aortic Root Redissection Following Surgical Repair for Acute Aortic Dissection Using Gelatin-Resorcin-Formalin Glue: Report of 2 Cases 　　Y. Sugawara, et al.…22

Late Aortic Root Redissection Following Surgical Repair for Acute Aortic Dissection Using Gelatin-Resorcin-Formalin Glue: Report of 2 Cases

(Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan)

Yuji Sugawara Katsuhiko Imai Kazuhiro Kochi

Kenji Okada Kazumasa Orihashi Taijiro Sueda

Gelatin-resorcin-formalin (GRF) glue has been generally applied in the surgical treatment of acute aortic dissection. Recently, midterm or late redissection and false anastomotic aneurysm following the use of this adhesive have been reported in several articles and the toxicity of its component has been suggested to be involved in this complication. We herein report 2 cases of aortic root redissection a few years after the initial surgery for type A acute aortic dissection. In another hospital, a 57-year-old man had undergone total arch replacement for acute dissection in which the proximal end was repaired using GRF glue. The aortic root was revealed to be redissected by computed tomography (CT) 2 years after the intervention and continued to enlarge since then. This aortic complication was treated by composite graft replacement. The intraoperative findings of marked degeneration in dissected root tissue were impressive. The other patient was a 71-year-old man. He had undergone prosthetic replacement of the ascending aorta associated with aortic valve resuspension using GRF glue for acute dissection. Three years later, symptoms of cardiac failure due to aortic regurgitation (AR) occurred and necessitated surgical correction. The AR was due to the redissection of the non-coronary cusp sinus. Repair of the coronary sinus and aortic valve replacement was performed. The postoperative course was uneventful in both cases. Other papers have cautioned that this tissue adhesive should not be used in aortic valve resuspension. Intensive long-term follow-up is required for aortic dissection patients surgically treated using this glue.
　Jpn. J. Cardiovasc. Surg. 33: 22 -25 (2004)

Acute Stanford Type B Aortic Dissection after Endoluminal Grafting for the Treatment of Descending Thoracic Aortic Aneurysms 　　H. Midorikawa, et al.…26

Acute Stanford Type B Aortic Dissection after Endoluminal Grafting for the Treatment of Descending Thoracic Aortic Aneurysms

(Department of Cardiovascular Center, Fukushima Daiichi Hospital, Fukushima, Japan)

Hirofumi Midorikawa Tomohiro Ogawa Kouichi Satou

Masayuki Koyama Shunichi Hoshino

A 65-year-old patient underwent successful transluminally placed endoluminal prosthetic grafts (TPEGs) of a descending thoracic aortic aneurysm (dTAA). Two hours after TPEGs, the patient suddenly complained of chest, back pain and right leg pain. Angiography and computed tomography showed acute type B aortic dissection. Re-TPEGs was immediately performed, and the entry was successfully closed. This case suggests that TPEGs for the treatment of acute aortic dissection may be useful for selected patients.
　Jpn. J. Cardiovasc. Surg. 33: 26 -29 (2004)

An Alternative to Total Arch Replacement for Type A Aortic Dissection 　　K. Furukawa, et al.…30

An Alternative to Total Arch Replacement for Type A Aortic Dissection

(Department of Cardiovascular Surgery, Nobeoka Prefectural Hospital, Nobeoka, Japan and Second Department of Surgery, Miyazaki Medical College*, Miyazaki, Japan)

Kouji Furukawa Masachika Kuwabara Eisaku Nakamura

Masakazu Matsuyama Toshio Onitsuka*

The total arch replacement protocol using the open-style stent-graft placement is frequently performed for type A aortic dissection to obtain complete closure of entry sites. However the open-style stent-graft placement must be carefully planned when the entry site is in the descending aorta and extends beyond the level of the tracheal bifurcation, because spinal cord ischemia can be caused due to occlusion of lower thoracic intercostal arteries. We report an alternative to total arch replacement for type A aortic dissection with entry in the ascending aorta and aneurysmal re-entry in the descending aorta, beyond the level of the tracheal bifurcation. We inserted a guide-wire from the dissected area of the aortic arch towards the normal region beyond the re-entry in the descending aorta, with confirmation by direct ultrasonography and already incised half, introduced a graft into the descending aorta using the wire as a guide and performed anastomosis at the level of the transverse aortotomy in the inclusion method. This operation has the advantage of preventing spinal cord ischemia because the re-entry site in the descending aorta is confirmed by direct ultrasonography and the distal anastomosis does not reach the lower thoracic intercostal arteries. In this method, by which the prosthesis is introduced through the descending aorta and anastomosed in the inclusion method, is not needed troublesome treatment in the descending aorta and less invasive than conventional single-stage total arch replacement and applicable with the great safe for aortic dissection that had shown difficulty in application of open-style stent-graft placement.
　Jpn. J. Cardiovasc. Surg. 33: 30 -33 (2004)

Two Cases of Stent-Grafting for Ruptured Aneurysms 　　I. Ichinoseki, et al.…34

Two Cases of Stent-Grafting for Ruptured Aneurysms

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

Ikkoh Ichinoseki Kazuo Itoh Mamoru Munakata

Masayuki Koyama Yasuyuki Suzuki Kozo Fukui

Shunichi Takaya Ikuo Fukuda

In cases of stent-grafting for ruptured aneurysm, endoleak is a serious problem. We report 2 cases of ruptured aneurysms that were treated with endovascular stent-graft placement. Case 1: A 79-year-old woman had a ruptured thoracic aortic aneurysm that was treated with endovascular stent-grafting from the distal arch to the descending aorta. Although her intra-operative course was uneventful, she died suddenly the day after operation. Autopsy revealed re-rupture of the aneurysm due to endoleak from the proximal site. Case 2: An 84-year-old woman was treated with endovascular stent-grafting for ruptured abdominal aortic aneurysm. The stent-graft was inserted from the infra-renal abdominal aorta to the right common iliac artery with femoro-femoral crossover bypass placement. There was evidence of type II endoleak that occurred via the left internal iliac artery（IIA）and inferior mesenteric artery（IMA）16 days after surgery. A CT scan performed 6 months after surgery revealed an increase in aneurysm size and persistent type II endoleak. Both embolization of the aneurysmal sac through the IMA and surgical ligation of the IMA failed, and endoleak from the IMA persisted. Re-rupture of the aneurysm occurred 10 months after initial surgery and emergency open surgery was performed. In stent-grafting for ruptured aneurysms, only the thrombus outside the graft resists the pressure caused by the endoleak. We conclude that endoleak after stent-grafting for ruptured aneurysm should be treated completely as soon as possible because of the risk of re-rupture.
　Jpn. J. Cardiovasc. Surg. 33: 34 -37 (2004)

Autotransplantation and Concomitant Pneunectomy for an Intracardiac Metastatic Lesion and Primary Pulmonary Blastoma of the Left Lung 　　M. Yamagishi, et al.…38

Autotransplantation and Concomitant Pneunectomy for an Intracardiac Metastatic Lesion and Primary Pulmonary Blastoma of the Left Lung

(Division of Pediatric Cardiovascular Surgery, Children's Research Hospital, Kyoto, Japan and Divison of Thoracic Surgery, Kyoto Prefectural University of Medicine*, Kyoto, Japan)

Masaaki Yamagishi Keisuke Shuntoh Tsutomu Matsushita

Akiyuki Takahashi Katsuji Fujiwara Takeshi Shinkawa

Takako Miyazaki Nobuo Kitamura Shougo Toda*

Pulmonary blastoma is rare and its prognosis very poor. A 6-year-old boy was referred to our hospital with chest pain. Computed tomography demonstrated that the left pleural cavity was filled with a tumor. Cardiac echocardiography demonstrated that the tumor had invaded through the pulmonary vein into the left atrium and that the tumor extended into the left ventricle. Part of the tumor was adhered to the anterior leaflet of the mitral valve. To increase operative radicality, an autotransplantation technique was performed concomitantly with resection of the original lesion. Through a median sternotomy, a moderate hypothermic cardiopulmonary bypass was established to obtain cardiac arrest. First, longitudinal incision of right-sided of the left atrium was made. The tumor invaded into the left atrium through the left superior pulmonary orifice. The ascending aorta, the main pulmonary artery, and both caval veins were transected. The left atrium was incised along the pulmonary venous orifices. The heart was completely removed from the mediastinum and transferred to another table. Resection of the intracardiac metastatic lesion and mitral valve replacement was accomplished. During this time, thoracic surgeons performed a left pneunectomy. The left atrial wall around the left pulmonary venous orifices was resected in combination with the left lung. After the deficit of the left atrial wall was repaired with a Gore-Tex patch, the heart was replaced and we reconstructed the great arteries and caval veins. The autotransplantation technique is a useful procedure for combined lesions of the heart and lung.
　Jpn. J. Cardiovasc. Surg. 33: 38 -41 (2004)

Mitral Valve Repair in an Adult Case of Marfan's Syndrome 　　M. Yoshikai, et al.…42

Mitral Valve Repair in an Adult Case of Marfan's Syndrome

(Department of Cardiovascular Surgery, Shin-Koga Hospital, Kurume, Japan)

Masaru Yoshikai Junichi Murayama Keiji Kamohara

Yasushi Hisamatsu

We present a case of successful mitral valve repair in a 38-year-old woman with Marfan's syndrome. Prolapse in a redundant billowing posterior mitral leaflet caused severe mitral valve regurgitation. Only slight dilatation of the sinus Valsalva and grade I aortic regurgitation were recognized. At operation, prolapsed portions seen on both sides of the middle scallop were quadrangularly resected. The sliding leaflet technique reduced the height of the posterior mitral leaflet to prevent systolic anterior motion of the mitral valve, which could be expected to occur after the operation. The anterior extremities of the Carpentier-Edwards annuloplasty ring were bent upward to accommodate the shape of the anterior mitral leaflet. Mitral valve regurgitation disappeared postoperatively, and she is now doing well 3 years after the operation. In general, isolated mitral valve regurgitation appears in relatively young patients with Marfan's syndrome, and these patients are at high risk of developing aortic dissection and aortic regurgitation. Therefore, mitral valve repair should be performed to improve the quality of life after the operation, and to reduce the risk of bleeding, which may be a lethal complication in aortic surgery.
　Jpn. J. Cardiovasc. Surg. 33: 42 -44 (2004)

Four Cases of Valvular Injury in Nonpenetrating Cardiac Trauma 　　Y. Yokoyama, et al.…45

Four Cases of Valvular Injury in Nonpenetrating Cardiac Trauma

(Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Japan)

Yukifusa Yokoyama Shuji Tamaki Noriyuki Kato

June Yokote Masato Mutsuga Norihisa Ohata

Toshihiko Suzuki

We report 4 cases of valvular injury following nonpenetrating cardiac trauma in 3 men and 1 woman ranging in age from 24 to 72 years. In all cases the cause of trauma was blunt chest trauma. One patient was operated in 4 h, but the other 3 patients were operated on more than 6 months after the accidents. Lacerated aortic cusp was observed in 2 patients, ruptured anterior papillary muscle of mitral valve, and ruptured chordae tendinae of the tricuspid vale were observed in 1 patient each respectively. Three patients underwent valve replacement（2 aortic and 1 mitral valves), and another patient underwent chordoplasty in the tricuspid valve. Their post-operative courses were uneventful. Careful observation, such as echocardiography, were required following the blunt chest trauma.
　Jpn. J. Cardiovasc. Surg. 33: 45 -49 (2004)

A Case of Atrial Septal Defect and Atrial Fibrillation with Idiopathic Thrombocytopenic Purpura 　　H. Watanabe, et al.…50

A Case of Atrial Septal Defect and Atrial Fibrillation with Idiopathic Thrombocytopenic Purpura

(Department of Cardiovascular Surgery, Fukaya Red-Cross Hospital, Fukaya, Japan)

Hiroyuki Watanabe Hideyuki Nakano Atsushi Tamura

A 53-year-old woman with atrial septal defect (ASD) and atrial fibrillation (AF) with idiopathic thrombocytopenic purpura (ITP), was scheduled to undergo ASD closure and the maze procedure. Because steroid therapy was not effective, high-dose γ-globulin administration (400mg/kg/day) was performed for 5 days before surgery. The platelet count increased from 5.4×10⁴/mm³ to 14.0×10⁴/mm³. ASD patch closure and modified bilateral appendage preserving (BAP) maze procedure were performed. No hemorrhagic tendency was recognized. The postoperative course was uneventful, and the sinus rhythm was recovered. The maze procedure become possible in this ITP patient with preoperative administration of high-dose γ-globulin.
　Jpn. J. Cardiovasc. Surg. 33: 50 -52 (2004)

A Case of Endovascular Stent Graft Repair for Traumatic Thoracic Aortic Aneurysm in a Young Patient with Multiple Injuries 　　T. Mizumoto, et al.…53

A Case of Endovascular Stent Graft Repair for Traumatic Thoracic Aortic Aneurysm in a Young Patient with Multiple Injuries

(Department of Thoracic Surgery, Anjo Kosei Hospital, Anjo, Japan, Departments of Thoracic and Cardiovascular Surgery, Shingu Municipal Medical Center*, Shingu, 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 16-year-old boy with multiple injuries suffered in a motorcycle accident was admitted to our hospital. On admission, X-ray films showed left hemothorax and bone fractures of the left humerus, thigh bone, and pelvis. Computed tomography of the chest revealed a pseudoaortic aneurysm approximately 6.0cm in diameter at the proximal portion of the descending aorta. Because of multiple severe associated injuries, we considered that conventional aortic repair in the acute phase would be difficult. We therefore performed an endovascular stent-graft treatment 140 days after injury. The postoperative course was uneventful and the pseudoaneurismal sac has confirmed to decrease. Transluminal placement of endovascular stent-graft is a technically feasible method for treatment of traumatic aortic aneurysm. However, because the long-term results are still unknown, we should follow-up carefully, particularly in young patients.
　Jpn. J. Cardiovasc. Surg. 33: 53 -56 (2004)

Spontaneous Rupture of the Abdominal Aorta in a Young Adolescent 　　Y. Tosaka, et al.…57

Spontaneous Rupture of the Abdominal Aorta in a Young Adolescent

(Department of Cardiovascular Surgery and Emergency and Critical Care Medical Center*, Niigata City General Hospital, Niigata, Japan)

Yuko Tosaka Hiroshi Kanazawa Yoshiki Takahashi

Satoshi Nakazawa Yoshihiko Yamazaki*

We describe a young adolescent patient with spontaneous abdominal aortic rupture who was treated successfully. A 14-year-old boy was admitted to our hospital with severe abdominal pain and hypovolemic shock, without any episode of trauma. Computed tomography (CT) revealed massive hematoma in the retroperitoneal space and extravasation of copious amounts of contrast medium in front of the terminal aorta. Neither aortic aneurysm nor dissection was observed in this CT. An emergency operation was carried out. At first, left thoracotomy and clamping of the thoracic descending aorta were performed in order to reduce the aortic bleeding. Midline laparotomy revealed an aortic perforation of approximately 8mm at the bifurcation of the abdominal aorta. The aortic wall surrounding the perforation was nearly normal without any aortic aneurysm or dissection. A segment of the terminal aorta (length, 3cm) including the perforated lesion was excised and reconstruction was performed with a woven Dacron tube graft (10mm in diameter). On microscopic examination, the marginal tissue near the perforation showed diminished elastic fibers and minimal dissection of the medial layer of the aortic wall; however, no cystic medial necrosis or inflammation was seen.
　Jpn. J. Cardiovasc. Surg. 33: 57 -60 (2004)

A Case of Tumor-Like Thrombus in the Distal Aortic Arch 　　S. Hamanaka, et al.…61

A Case of Tumor-Like Thrombus in the Distal Aortic Arch

(Division of Thoracic and Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan)

Sohei Hamanaka Kazuo Tanemoto Hisao Masaki

Ichirou Morita Atsushi Tabuchi Atsuhisa Ishida

Eishun Shishido Hiroshi Kubo

We report a 65-year-old man with a mobile thrombus in the distal aortic arch with no previous history of thromboembolic events. There was no evidence of either aneurysmal changes or aortic dissection. Transesophageal echocardiography revealed the presence of a mobile tumor in the distal arch. The patient underwent elective resection. The mobile tumor was attached to the aortic wall, approximately 3cm distal to the left subclavian artery. Histological examination revealed an old thrombus containing calcification. He was discharged on the 22nd postoperative day with no thromboembolic complications. This is the first report of a case of mobile thrombus in the distal aortic arch in Japan.
　Jpn. J. Cardiovasc. Surg. 33: 61 -63 (2004)

A Case of Myocardial Abscess Complicating Mitral Valve Infective Endocarditis due to Klebsiella pneumoniae 　　M. Yoshida, et al.…64

A Case of Myocardial Abscess Complicating Mitral Valve Infective Endocarditis due to Klebsiella pneumoniae (Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Japan) Masato Yoshida Nobuhiko Mukohara Hidefumi Obo Keitaro Nakagiri Hiroya Minami Tomoki Hanada Ayako Maruo Hironori Matsuhisa Naoto Morimoto Tsutomu Shida A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. Klebsiella pneumoniae was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus. Jpn. J. Cardiovasc. Surg. 33: 64 -67 (2004)

A Case of Metastatic Left Ventricular Tumor Causing Acute Lower Limb Embolisms 　　T. Kazui, et al.…68

A Case of Metastatic Left Ventricular Tumor Causing Acute Lower Limb Embolisms

(Department of Cardiovascular Surgery, Memorial Heart Center, Iwate Medical University, Morioka, Japan, Emory Crawford Long Hospital*, NE Atlanta, U.S.A. and Department of Cardiovascular Surgery, Nakadori General Hospital**, Akita, Japan)

Toshinobu Kazui Hajime Kin* Yoshiyuki Kamigaki**

Tadashi Okubo**

A 76-year-old man was admitted complaining of sudden right lower limb pain. Echocardiography showed occlusion of the right femoral artery. He underwent thrombectomy and regained his lower limb circulation. Two days after the operation, the patient suffered cardiopulmonary arrest. He was resuscitated and immediately after the resuscitation, echocardiography revealed a left ventricular mass that almost fell into the left ventricular out-flow tract. Emergency surgery was performed to remove the mass. Pathological testing showed that the mass was a metastatic transitional carcinoma. Fourteen days after the open-heart surgery, the patient suddenly developed left lower limb pain. We performed an emergency thrombectomy so that limb perfusion could recover quickly. The pathological diagnosis was embolism from a tumor of the left ventricle. His postoperative progress was rapid and he died 23 days after the open-heart surgery.
　Jpn. J. Cardiovasc. Surg. 33: 68 -71 (2004)