|Strategy for Abdominal Aortic Aneurysm Repair in Patients with Ischemic Heart Disease|
|Abdominal aortic aneurysms (AAA)
are frequently associated with clinically significant coexistent
ischemic heart disease (IHD). Cardiac events are the most common
cause of death after AAA repair. Preoperative coronary evaluation
and revascularization have been recommended to reduce postoperative
cardiac complications following AAA repair. In this study, we
retrospectively reviewed all patients who underwent AAA repair
and compared operative results in patients with and without IHD.
Of 388 patients who underwent elective AAA repair, 382 (98.5%)
had aortography and coronary angiography for preoperative evaluation.
Significant coronary artery disease was seen in 124 patients
(32.5%). As a result of the evaluation, 46 patients (12.0%）were
considered candidates for medical therapy, 18 for percutaneous
coronary intervention (PCI), and 60 for coronary artery bypass
grafting (CABG). In 24 patients (6.3%) who needed CABG and had
large sized AAAs (＞60mm), simultaneous CABG and AAA repair were
performed. In the remaining 36 patients (9.4%) who needed CABG
and had medium sized AAAs (40mm＜, ＜60mm), staged operation was
performed. We performed retrospective review comparing postoperative
cardiac events and operative mortality among these treatment
groups. There were 5 operative deaths (5/388, 1.3%) in patients
following AAA repair. There were 2 operative deaths (2/124, 1.6%)
in patients with significant IHD and 3 deaths (3/258, 1.2%) without
IHD. In patients with IHD, 1 patient who received medical therapy
died of acute renal failure and another one who received PCI
died of acute myocardial infarction. There were no operative
deaths or cardiac-related events in patients who received CABG
before or concomitant AAA repair. There was only 1 cardiac-related
event in all patient groups following AAA repair. Coronary arteries
were preoperatively evaluated in almost all patients with AAA.
If IHD was significant, the treatment for the IHD preceded AAA
repair. Our strategy succeeded in reducing operative mortality
and cardiac-related events in patients with both AAA and IHD.
If a patient with a large sized AAA (＞60mm) needs CABG, one-stage
operation is recommended.
Jpn. J. Cardiovasc. Surg. 33: 73-76 (2004)
|Clinical Evaluation of SJM Prosthetic Aortic Valve by Doppler Echocardiography: Application of Energy Loss Index (ELI) as a New Index of Aortic Prosthetic Valve Function|
|Although the pressure gradient (PG)
and the effective orifice area (EOA) have been used as indices
of prosthetic valve function, these values show correctly neither
energy loss, nor increased workload. This study aimed to evaluate
the prosthetic valve function using echocardiography and PG,
EOA and energy loss index, a new index advocated by Garcia et
al. These were calculated for 40 patients with aortic prosthetic
valve replacement by SJM valve (19HP, 6 cases; 21mm, 16 cases;
23mm, 14 cases; 25mm, 4 cases). Preoperative and postoperative
echocardiographic measurements and their variations were analyzed
and compared according to the size of implanted valve. In the
comparison before and after aortic valve replacement, left ventricular
mass (383±151g vs 288±113g, p＜0.01), SV1＋RV5 on ECG (5.07±1.73mV
vs 3.83±1.5mV, p＜0.01), and diastolic left ventricular
posterior wall thickness (14.4±3.7mm vs 12.9±2.8mm, p＜0.05)
decreased significantly after the operation. However, there was
no significant difference according to the size of the prosthetic
valve in these reduction rates caluculated by (preoperative value－postoperative
value)/preoperative value. Small size prosthetic valves were
used for patients with small diameter of left ventricular outflow
tract (LVOT) (19HP, 18±2mm; 21mm, 21±2mm; 23mm, 23±4mm; 25mm,
27±3mm; p＜0.01) and small body surface area (19HP, 1.5±0.2m²;
21mm, 1.5±0.2m²; 23mm, 1.7±0.1m²; 25mm, 1.8±0.1m²;
p＜0.01) in our study. There was a significant difference
in EOA (19HP, 1.2±0.4cm²; 21mm, 1.9±0.7cm²; 23mm, 2.2±0.9cm²;
25mm, 3.5±1.1cm²; p＜0.01), but not in ELI (19HP,
1.01±0.41cm²/m²; 21mm, 1.87±1.03cm²/m²; 23mm,
1.83±1.09cm²/m²; 25mm, 3.08±1.21cm²/m²; p＝0.055)
according to the size of the prosthetic valve. Small size prosthetic
valves had small EOA, but showed satisfactory valve function
in decreasing left ventricular hypertrophy and reducing LVM and
ELI of small size was similar to that of large size.
Jpn. J. Cardiovasc. Surg. 33: 77-80 (2004)
|Bifurcated Endovascular Graft for Abdominal Aortic Aneurysm Repair: A Multi-Center Trial of the PowerWeb™ System|
|Infra-renal abdominal aortic aneurysms
were electively treated by bifurcated endovascular stent grafts
(PowerWeb™ system, Endologix Co., USA) at 5 Japanese centers.
The stent grafting (SG) was applied for candidates nominated
by the selection committee after informed consent was obtained
according to the IRB in each center. The delivery success rate
of 60 patients (53 males) was 96.7%. There were 2 patients with
type I endoleaks, resulting in a technical success rate of 93.3%.
The operation time of 193±55 min and blood loss of 440±240 g
were significantly shorter and less, respectively in the SG group
when compared with 303±88 min and 1,496±2,025 g in 97 patients
(83 males) treated by conventional open surgery. Endoleaks were
detected in 4 patients (type I: 3, type II: 1) by CT scan taken
at the time of discharge or 1 month after SG procedure. Type
I endoleak was observed in patients with short and severely angulated
SG landing zones. Renal artery obstruction, and temporary buttock
pain caused by internal iliac artery occlusion occurred, but
there was no hospital death. In 56 patients excluding an SG-unrelated
death and a dropout from surveillance, there was no secondary
endoleak or marked adverse events at all except 1SG limb occlusion
during a 6-month follow up period. The aneurysm size shrank in
26 patients and remained unchanged in 30 patients. No aneurysm
enlargement was observed. The PowerWeb™ system is appropriate
for minimally invasive surgery for abdominal aortic aneurysms.
Long-term follow-up studies will follow.
Jpn. J. Cardiovasc. Surg. 33: 81-86 (2004)
|Stent Grafting Using Matsui-Kitamura Stents for Patients with Distal Aortic Arch Aneurysm|
|Although several methods of stent grafting for patients with distal aortic arch aneurysm have been reported, these methods had several complications such as endoleak, migration, or cerebrovascular accident. We developed a new stent grafting method using the MK stent-graft (Matsui-Kitamura stent-graft, Kitamura Inc., Kanazawa, Japan) following bypass grafting of arch vessels under left heart bypass. We performed this method for 3 patients associated with severe pulmonary dysfunction or renal dysfunction. There were no postoperative complications, endoleak or migration. All 3 patients were discharged in good condition. It is concluded that this method might be useful method for patients with distal aortic arch aneurysm complicated by severe organ dysfunction, or in elderly patients.
Jpn. J. Cardiovasc. Surg. 33: 87-89 (2004)
|A Case of Coronary Artery Bypass Grafting Using Arterial Grafts in a Patient with Systemic Lupus Erythematosus and Review of the Literature|
|We report a case of coronary artery bypass grafting (CABG) in a patient with systemic lupus erythematosus (SLE). A 24-year-old woman with SLE had been treated with steroids and immunosuppressive agents for 7 years. The patient was admitted to Kumamoto University Hospital for the management of unstable angina. CABG was successfully performed using bilateral internal thoracic arteries and postoperative 3D-CT demonstrated good patency of both arterial grafts. The patient experienced no significant postoperative complications, and has remained well to date（8 months postdischarge).
Jpn. J. Cardiovasc. Surg. 33: 90-93 (2004)
|Nonocclusive Mesenteric Ischemia after Off-Pump CABG|
|An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.
Jpn. J. Cardiovasc. Surg. 33: 94-97 (2004)
|Successful One-Stage Resection of Intravenous Leiomyomatosis with Extension into the Main Pulmonary Artery|
|We report a case of successful one-stage resection of intravenous leiomyomatosis (IVL) with extension into the main pulmonary artery. The patient was a 50-year-old woman, who was admitted to our hospital with clinical signs of syncope. Computed tomography (CT) and 3D helical CT images showed a tumor arising in the left side of the uterus with extension into the pulmonary outflow tract. One-stage radical operation with cardiopulmonary bypass was performed. Because IVL is related to many fields concerning various organs, it is important that general surgeons, gynecologists and cardiovascular surgeons cooperate with each other.
Jpn. J. Cardiovasc. Surg. 33: 98-101 (2004)
|A Rare Combination of Impending Rupture of an Aortic Arch Aneurysm Associated with an Aberrant Right Subclavian Artery, Quadricuspid Aortic Valve and Idiopathic Thrombocytopenic Purpura|
|We report a case of a 64-year-old woman who was referred to our hospital complaining of hemoptysis and severe back pain. A chest computed tomography revealed impending rupture of the aortic arch aneurysm associated with an aberrant right subclavian artery. She had been treated with oral steroids for idiopathic thrombocytopenic purpura (ITP) with good control. She underwent emergency total aortic arch replacement under deep hypothermic circulatory arrest. Intraoperative transesophageal echocardiogram showed moderate aortic regurgitation and we found a quadricuspid aortic valve. Aortic valve replacement was also performed. Steroids were given intravenously during and after the operation as a steroid cover and platelets were transfused as well. Although her early postoperative course was uneventful, recurrence of ITP occurred 3 weeks after surgery. Increased dose of steroids caused the patient to be susceptible to infection. She suffered from high fever and suddenly died of massive hemoptysis due to dehiscence of the distal anastomosis caused by graft infection 60 days postoperatively. To the best of our knowledge, this is the second case report from Japan describing an aortic arch aneurysm repair in a patient with ITP and is also the first report of combined congenital anomalies with aberrant right subclavian artery and quadricuspid aortic valve.
Jpn. J. Cardiovasc. Surg. 33: 102-105 (2004)
|A Case of Successful Aortic Fenestration for Renal Failure Associated with Aortic Dissection|
|A 72-year-old woman suffered sudden back pain 42 days after ascending aortic replacement for retrograde acute type A aortic dissection. Computed tomography (CT) revealed type B aortic dissection and a stenotic true lumen at the abdominal aorta. The celiac artery and the superior mesenteric artery (SMA) branched from the true lumen, but bilateral renal arteries were not found by DSA. Infrarenal abdominal aortic fenestration was performed at 6th day from onset, because of progressive renal dysfunction. Intestinal ischemia was not confirmed by laparotomy. After the infrarenal aorta was clamped and transected, the proximal intima was resected in a U-shape. The proximal stump which was reinforced with teflon felt was anastomosed to an 18mm woven graft. Distal anastomosis was carried to the true lumen was carried out with closure of the false lumen. Regaining flow into the collapsed true lumen was observed by epiaortic echography. Postoperatively, continuous hemofiltration was required for several days until renal dysfunction was improved. CT showed reasonable expansion of the true lumen, and no findings of visceral ischemia except for partial infarction of the left kidney. DSA revealed that bilateral renal arteries were perfused from the true lumen through the fenestration. Neither aortic dilatation nor new ischemia have been recognized, but further close observation is necessary.
Jpn. J. Cardiovasc. Surg. 33: 106-109 (2004)
|Reoperations after Total Arch Replacement in Acute Type A Aortic Dissection|
|Gelatin-resorcin-formalin (GRF) glue has been widely used in repair of dissected aortic wall tissue, and the use of GRF glue has been reported to significantly reduce mortality from this surgical emergency. On the other hand, various late complications possibly due to GRF glue have also been reported. We performed reoperations after total arch replacement for acute type A aortic dissection using GRF glue in 2 cases. In case 1, total arch replacement was performed 3 years ago. Pseudoaneurysms of the aortic root and brachiocephalic artery and redissection of the descending aorta were revealed by subsequent computed tomography (CT). Partial graft replacement for these 3 sites were performed with open distal anastomosis and right common carotid artery perfusion. In case 2, total arch replacement was performed 5 years previously. Redissection of the aortic root was revealed by CT, and ultrasound cardiography revealed severe aortic regurgitation and severe mitral valve insufficiency. A modified Bentall procedure and mitral valve replacement were performed. In these 2 cases, the sites of redissection and pseudoaneurysm were identified as the sites of use of GRF glue at the first operation. We suspected that the use of GRF glue is associated with a certain amount of risk of redissection and pseudoaneurysm. Such patients should be carefully followed for years after surgery. It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue.
Jpn. J. Cardiovasc. Surg. 33: 110-113 (2004)
|Staged Arterial Switch Operation without Homologous Blood Transfusion|
|Staged arterial switch operation without homologous blood transfusion was successfully performed in 5 patients weighing 4.1-11.0kg (double outlet right ventricle: 2 cases, transposition of great arteries: 3 cases). The postoperative hemodynamics and respiratory status were uneventful in all patients (initial central venous pressure after ICU admission: 9.0-14.5cmH2O, mean 12.5cmH2O, duration of intubation: 3.5-18.0h, mean 7.8h). Autologous blood donation immediately after induction of anesthesia and minimization of bypass circuit were effective methods for open heart surgery without homologous blood transfusion, particularly in staged arterial switch operation requiring prolonged cardiopulmonary bypass.
Jpn. J. Cardiovasc. Surg. 33: 114-117 (2004)
|Persistent Sciatic Artery Revealed by Cellulitis and Skin Necrosis of the Lower Leg|
|A 59-year-old man was referred to our department for the treatment of cellulitis and skin necrosis after a bruise of the left lower leg. He had suffered from intermittent claudication of the left calf for a year and arterial pulses in the left lower limb were absent. Arteriogram showed hypoplasty of the left external iliac artery and aplasty of the left superficial femoral artery. A persistent sciatic artery was noted to be the dominant blood supply to the left lower extremity. Left ilio-popliteal artery bypass using 6mm ringed ePTFE graft was performed. After arterial reconstruction, skin transplantation was performed and the intermittent claudication disappeared completely.
Jpn. J. Cardiovasc. Surg. 33: 118-120（2004)
|Successful Management for Aortic Valve Insufficiency in a Childbearing Age Patient with Type II Ehlers-Danlos Syndrome|
|A 16-year-old schoolgirl had aortic valve insufficiency, detected incidentally on electrocardiogram taken for a physical checkup. She was noted to have hyperextensibility of joints, hyperelasticity of the skin and an atrophic scar over the knees on physical examination and type II Ehlers-Danlos syndrome (EDS) was diagnosed by skin biopsy after admission. A Carpentier-Edwards pericardial bioprosthesis was chosen for aortic valve replacement because she was of childbearing age and had EDS. Seven years after the replacement she became pregnant, resulting in spontaneous vaginal delivery of a healthy male infant at 39 weeks. However, a second aortic valve replacement was staged for structural failure of the bioprosthesis which was accelerated during the gestation. Aortic valve re-replacement was carried out using a 21-mm Sorin Bicarbon mechanical prosthesis 4 months after the delivery. She was discharged on the 10th postoperative day without any complications.
Jpn. J. Cardiovasc. Surg. 33: 121-124 (2004)
|An Octogenarian Case of Surgical Treatment for Ischemic Mitral Regurgitation|
|An 84-year-old woman was brought to our hospital with cardiogenic shock. Ischemic changes of the ST segment were observed on the electrocardiogram in broad leads, but Q waves were not. Echocardiography revealed severe mitral regurgitation due to prolapse of the posterior leaflet, and coronary angiography showed 2-vessel disease involving left coronary arteries accompanied by a hypoplastic right coronary artery, so the coronary lesion seemed to be equivalent to 3-vessel disease. Preoperative tracheal intubation and intraaortic balloon pump (IABP) were required to maintain the hemodynamics. Emergency surgical procedures of combined coronary artery bypass grafting with mitral valve replacement were performed successfully. After 18 days, the patient was discharged, classified as NYHA class II. The prognosis for acute ischemic mitral regurgitation presenting shock in an octogenarian is extremely poor. Although the clinical symptoms were serious in this case, partial rupture of the papillary muscle and subendocardial infarction contributed to the favorable surgical result.
Jpn. J. Cardiovasc. Surg. 33: 125-128 (2004)
|Aortic Valve Replacement Associated with Essential Thrombocythemia|
|Essential thrombocythemia is a rare
disease belonging to the group of chronic myeloproliferative
disorders. It displays both thrombogenic and bleeding tendencies
due to increased platelet counts, as well as dysfunction. Aortic
valve replacement with a 23mm Carpentier-Edwards bioprosthesis
was performed for a 74-year-old man with aortic stenosis associated
with essential thrombocythemia. No pre-treatment was performed
before surgery, though the platelet count was 80×104/μl. During
the surgery, activated coagulation time was kept over 400 sec
with heparin. There was no difficulty with hemostasis. Aspirin
and warfarin were used as antiplatelet and anticoagulant agents
after surgery, so the thrombin test results were controlled at
around 30%. Since the platelet count reached 130×104/μl, hydroxyurea
as chemotherapy was given to suppress the platelet count below
100×104/μl. The operation was completed without major problems
and the postoperative course was uneventful. This patient remains
in good condition.
Jpn. J. Cardiovasc. Surg. 33: 129-132 (2004)
|A Case of External Iliac Artery Occlusion after Total Hip Arthroplasty|
|A case of external iliac artery occlusion after total hip arthroplasty (THA) is reported. A 65-year-old man had undergone a left THA 8 years previously. He had intermittent claudication involving his left calf, and the ankle pressure index (API) of the left leg was 0.56. Digital subtraction angiography revealed local occlusion of the left external iliac artery, which was consistent with the surgical field of THA. A left external ilio-common femoral bypass was performed without incident. The risk of vascular complication associated with THA is low, and especially so in cases with iliac arterial occlusion. However, adequate and prompt diagnosis is required in such cases.
Jpn. J. Cardiovasc. Surg. 33: 133-135 (2004)
|A Surgical Case for Extracardiac Unruptured Giant Aneurysm of the Right Sinus of Valsalva|
|A 64-year-old man was admitted to our hospital because of a feeling of compression of the chest 5 years previously. Aneurysm of the right sinus of Valsalva was unexpectedly diagnosed by detailed examinations. He was admitted for the surgery, because dilated aneurysm caused severe stenosis of right ventricular outflow tract (RVOT) and aortic regurgitation (AR) progressed. He underwent surgical repair consisting of patch closure of the aneurysm, aortic valve replacement, right coronary artery (RCA) bypass grafting with right internal thoracic artery (RITA), and aneurysmal wall was closed with suture after partial resection. The postoperative course was uneventful. Postoperative angiography revealed that aneurysm of the right sinus of Valsalva was not enhanced and the RITA graft was patent. The pressure gradient between RV and PA immediately reduced after operation. Postoperative CT showed that the stenosis of the RVOT completely disappeared with the elimination of the aneurysm.
Jpn. J. Cardiovasc. Surg. 33: 136-139 (2004)
|Operation with Cardiopulmonary Bypass Using Heparin and Nafamostat Mesilate for a Patient with Protamine Allergy|
|A 77-year-old woman was given general anesthesia for an ascending aortic aneurysm operation and went into anaphylactic shock. The operation was canceled. Vecuronium, pancuronium, protamine and famotidine revealed positive prick test reactions. Ascending aortic replacement underwent under minimum dose of heparin for cardiopulmonary bypass (CPB). Heparin was injected immediately before CPB (2.5mg/kg) and nafamostat mesilate was injected continuously during CPB (2mg/kg/h). The ACT value was over 1,400sec during CPB. However, protamine was not used after CPB. The operation time was 4h and 30min. CPB time was 1h and 26min. After the patient returned to the ICU, bleeding from the chest drainage tubes increased temporarily. The bleeding decreased gradually after administration of FFP and MAP.
Jpn. J. Cardiovasc. Surg. 33: 140-142 (2004)
|A Case of True Brachial Arterial Aneurysm|
|An extremely rare case of true brachial arterial aneurysm due to blunt trauma is reported. A 55-year-old male suffered from blunt trauma in his right upper arm when he was 8 years old. He had noticed a mass in his right upper arm for more than 30 years, however, it grew rapidly to 7×6×5cm within several months. Digital subtraction angiography revealed a large saccular aneurysm of the right brachial artery. The aneurysm was removed and replaced by a saphenous vein graft.
Jpn. J. Cardiovasc. Surg. 33: 143-146 (2004)