Japanese Journal of Cardiovascular Surgery Vol.33, No.3

Originals

Profound Hypothermia-Induced Platelet Dysfunction during Heparinized Cardiopulmonary Bypass 　　O. Shigeta, et al.…147

Profound Hypothermia-Induced Platelet Dysfunction during Heparinized Cardiopulmonary Bypass

(Department of Cardiovascular Surgery, Institute of Clinical Medicine, Tsukuba University, Tsukuba, Japan and Tsukuba Medical Center Hospital*, Tsukuba, Japan)

Osamu Shigeta Yuji Hiramatsu Tomoaki Jikuya*

Yuzuru Sakakibara

There is an impression among cardiothoracic surgeons that the technique of profound hypothermic circulatory arrest (PHCA) is associated with an increased bleeding tendency compared to conventional bypass surgery. In addition to the recognized factors contributing to the hemorrhagic tendency seen in moderate hypothermic cardiopulmonary bypass (CPB), it is likely that the lower temperature utilized in PHCA may exacerbate platelet dysfunction. In this report, platelet counts and functions at the same cardiopulmonary bypass time were compared in human PHCA surgery (hypothermia group, n＝16) and moderate hypothermic cardiopulmonary bypass surgery (control group, n＝20). Mean platelet count corrected by hematocrit in the hypothermia group at 2 h of CPB was significantly lower than in the control group (3.7×10⁴µl vs. 11.4×10⁴/µl, p＜0.0001). In the hypothermia group, there were significant increases in the percentage of GMP-140 (P-selectin)-positive platelets (11.8% vs. 8.3%, p＝0.0091) at 1 h of CPB, and also in microparticles (24.8% vs. 10.5%, p＜0.0001) and aggregated platelets (3.4% vs. 1.4%, p＝0.0058) at 2h of CPB. Profound hypothermic circulatory arrest used in surgery for aortic arch aneurysm or dissection may cause irreversible platelet dysfunction and contribute to hemorrhagic tendency during the surgery. To minimize platelet dysfunction during CPB, the lowest blood temperature should be maintained above 15°C.
　Jpn. J. Cardiovasc. Surg. 33: 147-151 (2004)

Acute Aortic Dissection Combined with Obstructive Sleep Apnea Syndrome 　　T. Sumiyoshi, et al.…152

Acute Aortic Dissection Combined with Obstructive Sleep Apnea Syndrome

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

Tatsuaki Sumiyoshi Hiroshi Ishihara Naomichi Uchida

Masamichi Ozawa

Obstructive sleep apnea syndrome (OSAS) has symptoms such as severe snoring, apneic attack, and daytime hypersomnia due to repeated obstruction of the upper respiratory tract during sleep. The mortality rate due to cardiovascular complications in severe OSAS. We reported 5 cases of OSAS among the acute aortic dissection cases we treated. They were 2 cases of DeBakeyI (cases 1, 2) and 3 cases of IIIb (cases 3, 4, 5). Organ ischemia was recognized in 4 among 5 cases of dissection combined with OSAS. There was 1 case of renal ischemia (case 1), 2 cases of limb ischemia (cases 3, 4), 1 case of visceral and spinal ischemia (case 5). Case 4 was IIIb type dissection with severely compressed true lumen and limb ischemia. The false lumen occluded by combining antihypertensive therapy and continuous positive airway pressure used to OSAS. Case 5 also had a severely compressed true lumen, and visceral ischemia 4 days after the onset. Angiography showed a severly compressed orifice of the true lumen of the celiac artery and superior mesentric artery due to the occluded false lumen. We placed a stent into the orifice of celiac artery transluminally and then patient recovered. There were many dangerous situations such as organ ischemia, and severely compressed true lumen among the cases of dissection combined with OSAS. Marked changes of intrathoracic pressure in apneic attacks may place stress on the thoracic aorta.
　Jpn. J. Cardiovasc. Surg. 33: 152-157 (2004)

Case Reports

Simultaneous Axillo-Axillary Crossover Bypass Grafting and Off-Pump CABG Using Bilateral Internal Thoracic Arteries in a Patient with Severe Atherosclerosis in Both the Ascending Aorta and Proximal Left Subclavian Artery 　　Y. Iba, et al.…158

Simultaneous Axillo-Axillary Crossover Bypass Grafting and Off-Pump CABG Using Bilateral Internal Thoracic Arteries in a Patient with Severe Atherosclerosis in Both the Ascending Aorta and Proximal Left Subclavian Artery (Department of Cardiovascular Surgery, Heart Center, St. Luke's International Hospital, Tokyo, Japan) Yutaka Iba Sunao Watanabe Takehide Akimoto Kouhei Abe Hitoshi Koyanagi Combined surgery for left subclavian artery revascularization and CABG was performed in a 74-year-old man with diabetes mellitus. The preoperative coronary angiogram showed critical stenoses in all three major branches, and arteriography revealed obstruction at the left proximal subclavian artery. Severe atherosclerotic calcification was acknowledged circumferentially in the ascending aorta and in the aortic arch. For this patient axillo-axillary crossover bypass grafting was performed first using and expanded PTFE graft, followed subsequently by off-pump CABG using all in situ grafts (right internal thoracic artery-left anterior descending artery (RITA-LAD), left internal thoracic artery-diagonal branch (LITA-diagonal branch), gastro-epiploic artery-right coronary artery (GEA-RCA)). Postoperative recovery was smooth, with disappearance of significant pressure difference between both arms (preoperatively, 46mmHg). An angiogram on the 7th postoperative day showed a widely patent axillo-axillary bypass graft along with good flow of all three coronary grafts, in which LITA was visualized well through the axillo-axillary bypass graft. For complex atherosclerotic disease of the proximal aorta and incipient portion of neck vessels associated with severe coronary sclerosis, this technique is a suitable option. Jpn. J. Cardiovasc. Surg. 33: 158-161 (2004)

Abdominal Aortic Aneurysm Accompanied by Aortic Dissection 　　S. Tsukamoto, et al.…162

Abdominal Aortic Aneurysm Accompanied by Aortic Dissection

(Department of Cardiovascular Surgery, Surugadai Nihon University Hospital, Tokyo, Japan, Department of Cardiovascular Surgery, National Hospital Tokyo Disaster Medical Center*, Tachikawa, Japan and The Second Department of Surgery, Nihon University School of Medicine**, Tokyo, Japan)

Saeki Tsukamoto Yukihiko Orime Shoji Shindo*

Shinsuke Choh Masahiro Obana** Kenji Akiyama**

Motomi Shiono** Nanao Negishi**

Three cases of aortic dissection involving abdominal aortic aneurysms are reported. Two of the 3 cases died from intestinal necrosis. In one of them, the abdominal aortic aneurysm ruptured following aortic dissection. Fenestration was not performed at the proximal anastomosis in the operation, and it is thought that this resulted in occurrence of intestinal necrosis due to superior mesenteric artery obstruction. In the other non-survivor, aortic fenestration and graft replacement were performed. However, he died from descending―sigmoid colon necrosis due to internal iliac artery obstruction. An autopsy demonstrated no problem that with the graft anastomosis. The successful case of aortic fenestration and graft replacement had no postoperative complications. Since the aortic wall is fragile in acute aortic dissection, it is advisable that operation be conducted 1 month after the onset except in cases of aortic rupture and malperfusion syndrome. Fenestration, which is usually safe in chronic dissection, should be performed and it is desirable to fenestrate the aortic wall if possible even in acute dissection.
　Jpn. J. Cardiovasc. Surg. 33: 162-165 (2004)

A Case of Postinfarction Left Ventricular Free Wall Rupture in an Elderly Patient 　　I. Yoshitake, et al.…166

A Case of Postinfarction Left Ventricular Free Wall Rupture in an Elderly Patient

(Department of Cardiovascular Surgery, Okaya Enrei Hospital, Okaya, Japan and The Second Department of Surgery, Nihon University School of Medicine*, Tokyo, Japan)

Isamu Yoshitake Hiroaki Hata Tsutomu Hattori

Satoshi Unosawa Mitsuo Narata* Motomi Shiono*

Nanao Negishi* Yukiyasu Sezai*

An 85-year-old man was admitted complaining of chest pain. The ECG showed ST depression in leads II, III, _aV_F, V₃～V₆ and Q wave in leads I, _aV_L with elevation in ST segments. An emergency coronary angiography revealed 75% stenosis in the left main trunk, 75-90% stenosis in the left anterior descending artery, total occlusion in the acute marginal branch, 75% stenosis in the left circumflex artery, and 75% stenosis in the right coronary artery. He was treated medically, because he was old and his hemodynamics were stable. About 39h later, he lost consciousness suddenly and was shown to have cardiogenic shock. Echocardiogram revealed pericardial effusion. Percutaneous drainage was performed, resulting in improved blood pressure and level of consciousness. He was transferred to Okaya Enrei Hospital and received emergency surgery for subacute LVFWR. A sutureless repair and coronary bypass was performed under cardiopulmonary bypass and cardiac arrest. He experienced no major complication and was discharged 40 days after surgery. It is concluded that the sutureless technique allowed for a shorter operation time and concomitant coronary bypass successfully prevented pseudo-aneurysm and improved cardiac function. A higher quality operation is possible by using a combination of on-pump, cardiac arrest, coronary bypass and left ventricle repair with the sutureless technique in such cases in which treatment is needed for cardiac arrest as in the above example. This method contributed to an improved prognosis.
　Jpn. J. Cardiovasc. Surg. 33: 166-170 (2004)

A Case of Spontaneous Resolution of Systolic Anterior Motion after Mitral Repair 　　S. Isoda, et al.…171

A Case of Spontaneous Resolution of Systolic Anterior Motion after Mitral Repair

(Department of Cardiovascular Surgery, Saiseikai Yokohama-Shi-Nanbu Hospital, Yokohama, Japan)

Susumu Isoda Norihisa Karube Akira Sakamoto

Tamitaro Soma

A 70-year-old patient underwent modified maze procedure and mitral repair including quadrangular resection, annular plication (Reed procedure), and flexible ring annuloplasty with Cosgrove ring. Systolic anterior motion (SAM) of the anterior mitral leaflet and mild mitral regurgitation was observed on weaning from cardiopulmonary bypass. The patient was medically treated, and postoperative echocardiography revealed disappearance of the SAM 11 days after surgery. In addition to the surgical condition of rather excessive annular plication and small ring, transient conditions including inotropic support, insufficient volume under diastolic dysfunction of left ventricle, and loss of atrial contraction were thought to be the causes of SAM.
　Jpn. J. Cardiovasc. Surg. 33: 171-174 (2004)

A Case of Total Anomalous Pulmonary Venous Connection with Two Vertical Veins Draining to the Infracardiac Level 　　Y. Kunii, et al.…175

A Case of Total Anomalous Pulmonary Venous Connection with Two Vertical Veins Draining to the Infracardiac Level

(Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan)

Yoshifumi Kunii Masaaki Koide Yoshikazu Ayusawa

Infracardiac type total anomalous pulmonary venous connection (TAPVC) was diagnosed in a 1-day-old boy. We performed emergency total correction on day 1 and found 2 vertical veins draining to the infracardiac level separately. Each vertical vein was rerouted to the left atrium. On the first postoperative day, an extracorporeal membrane oxygenation was required because of respiratory failure. He died due to cerebral hemorrhage on the 5th day after the operation. Macroscopic findings showed the right sided vertical vein draining to the IVC, and the left sided one to the confluence of the hepatic vein and ductus venosus. Microscopic findings of the lung revealed markedly dilated lymphatics which was suspected as the cause of respiratory failure. Although cases with 2 separate vertical veins are very rare, the precise anatomy of PV return has to be checked intraoperatively when the preoperative identification has not been established.
　Jpn. J. Cardiovasc. Surg. 33: 175-177 (2004)

Patch Graft Aortoplasty for Repair of Chronic Aortic Dissection 　　S. Akishima, et al.…178

Patch Graft Aortoplasty for Repair of Chronic Aortic Dissection

(Department of Cardiovascular Surgery, Kitaibaraki City General Hospital, Kitaibaraki, Japan and Department of Surgery, Institute of Clinical Medicine, University of Tsukuba*, Tsukuba, Japan)

Shinji Akishima Junichi Sakurai Tomoaki Jikuya*

A 72-year-old woman was admitted as an emergency case to our hospital because of chest oppression. She had a history of admission due to the same symptoms about 9 months previously. Her chest computed tomography showed a dissection of the ascending aorta (DeBakey type II). We suspected an acute aortic dissection and an emergency operation with CPB was performed. The ascending aorta was markedly enlarged, but the dissected adventitia did not appear weakened. Moreover, there was no bloody pericardial effusion which is specific to acute aortic dissection. When the pseudo-lumen was exposed, a firm intimal flap and single entry hole were recognized. The chronic phase of aortic dissection was finally diagnosed. Then the dissected adventitia and intimal flap were removed and a patch graft aortoplasty with a tailored 26mm gelatin-impregnated knitted Dacron vascular graft was employed because the residual aortic wall was normal in size and consisting. Her postoperative course was uneventful and there was no evidence of recurrence of aortic dissection or enlargement 2 years after the operation. We conclude that patch aortoplasty for repair of chronic aortic dissection can be effective when the range of dissection is restricted and te residual aortic wall is normal.
　Jpn. J. Cardiovasc. Surg. 33: 178-181 (2004)

Aortic Valve Replacement Following Infectious Endocarditis Requiring Re-Operation Three Times 　　N. Sasahashi, et al.…182

Aortic Valve Replacement Following Infectious Endocarditis Requiring Re-Operation Three Times

(Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan and Department of Cardiovascular Surgery, Kyoto University*, Kyoto, Japan)

Nozomu Sasahashi Kazunobu Nishimura* Nobushige Tamura

Koji Ueyama

A 47-year-old man with active aortic valve endocarditis underwent direct closure of a paraannular abscess and valve replacement. Methicillin-resistant Staphylococcus aureus was isolated from his blood culture preoperatively. Because of a postoperative paravalvular leak (PVL) and an echo-free space suggesting a residual cavity, he was reoperated for patch closure of the aneurysm and prosthetic valve replacement. However, the PVL and paraannular cavity were still observed after the 2nd surgery. At the 3rd operation, prosthetic valve detachment along one fourth of its circumference was confirmed, and the cavity was fully opened. A patch was used to cover the pseudoaneurysm and was placed under the orifice of the left coronary artery. This patch repair of the cavity was accomplished, followed by prosthetic valve replacement in situ. Trivial PVL was identified after the operation, and a diagnosis of intravascular mechanical hemolysis was made. Clinical examination revealed partial detachment of the prosthetic valve resulting in a significant PVL and paraannular pseudoaneurysm. Because of unremitting hemolysis and the increased PVL, the patient underwent a 4th repair. Inspection showed that the prosthetic valve was partially detached and the defect was opened at the upper edge. The orifice of the aneurysmal was covered, and valve replacement was performed in the supraannular position using 3 U-stays, which were passed through both the aortic wall and the patch, followed by ascending aortic graft replacement. In the case of aortic valve endocarditis with paraannular involvement, radical debridement and complete reconstruction of the left ventriculoaortic discontinuity without tension are required.
　Jpn. J. Cardiovasc. Surg. 33: 182-184 (2004)

A Case of Pseudoaneurysm of the Ascending Aorta Found at Onset of Acute Aortic Dissection after Aortic Valve Replacement 　　K. Honda, et al.…185

A Case of Pseudoaneurysm of the Ascending Aorta Found at Onset of Acute Aortic Dissection after Aortic Valve Replacement

(Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan)

Kentaro Honda Keiichi Fujiwara Hiroyoshi Komai

Syuji Yamamoto Yoshitaka Okamura

A pseudoaneurysm of the ascending aorta is a complication found in aortic valve surgery. A 66-year-old man who had a previous history of aortic valve replacement due to infectious endocarditis was admitted to our hospital suffering from chest pain. Follow-up chest X-ray and transthoracic echocardiogram had revealed no findings of pseudoaneurysm during the intervening period. At admission, computed tomographic scan and transesophageal echocardiogram each showed a Type A acute aortic dissection and a pseudoaneurysm of the ascending aorta. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, an ascending aortic graft replacement was carried out uneventfully. The patient is well 14 months postoperatively. Postoperative examinations following aortic surgery should be performed not only from the view point of cardiac function, but also from that of a pseudoaneurysm.
　Jpn. J. Cardiovasc. Surg. 33: 185-188 (2004)

A Case Report of Delayed-Onset Lower Spinal Cord Injury after Replacement of the Aortic Arch and the Descending Thoracic Aorta Using a Stented Elephant Trunk 　　T. Kunihara, et al.…189

A Case Report of Delayed-Onset Lower Spinal Cord Injury after Replacement of the Aortic Arch and the Descending Thoracic Aorta Using a Stented Elephant Trunk

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

Takashi Kunihara Kenji Matsuzaki Norihiko Shiiya

Keishu Yasuda

Higher incidence of spinal cord injury has been reported in total aortic arch replacement using a stented elephant trunk compared with the conventional one, perhaps due to embolism of atheromatous plaque to the spinal cord arteries. We report a case with delayed-onset lower spinal cord injury after replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. A 69-year-old man who had a history of abdominal aortic aneurysm repair using a Y-graft and untreated Crawford’s type II thoracoabdominal aortic aneurysm underwent replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. He developed weakness of the lower extremities 4 days after the operation. Since a preoperative computed tomography demonstrated thrombus and atheroma in the aneurysm, atheromatous plaque that can cause embolization of the spinal cord arteries was suspected to be responsible for spinal cord injury. As this technique is mostly applied to patients with severe atheromatous aortic disease, embolization of the intercostal arteries or other main branches caused by manipulation of a stent graft must be avoided.
　Jpn. J. Cardiovasc. Surg. 33: 189-192 (2004)

A Case of Endoventricular Circular Patch Repair (Dor Operation) and CABG for Pseudo-False Ventricular Aneurysm of Left Ventricular Wall 　　M. Yamamoto, et al.…193

A Case of Endoventricular Circular Patch Repair (Dor Operation) and CABG for Pseudo-False Ventricular Aneurysm of Left Ventricular Wall

(Department of Cardiovascular Surgery, Daini Hospital, Tokyo Women's Medical University, Tokyo, Japan)

Masato Yamamoto Hiroshi Niinami Yuji Suda

Mimiko Tabata Ryota Asano Masahiro Ikeda

Yasuo Takeuchi

Aneurysms of the inferior left ventricular wall comprise only a small fraction of all aneurysms that have been reported in surgical series. Pseudo-false ventricular aneurysm is very rare and communicates with the left ventricule through a small orifice, and its wall contains myocardial tissue, unlike false ventricular aneurysm. A 53-year-old man was admitted to our hospital with chest pain. Echocardiography revealed left ventricular aneurysm, and the coronary arteriography subsequently revealed a complete occlusion of right coronary #2 and 75% and 90% stenosis of left anterior descending artery #7 and#8, respectively. Left ventriculography revealed an aneurysm of the inferior left ventricular wall, which communicated with the left ventricle through a small orifice and exhibited contraction. Surgical repair was indicated. Endoventricular circular patch repair (Dor operation) of the aneurysm of the inferior left ventricular wall and coronary artery bypass grafting to the left anterior descending artery and the right coronary artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The postoperative course was uneventful and the patient was discharged on the 22th day after surgery. Pseudo-false ventricular aneurysm of the inferior left ventricular wall was diagnosed by pathologic examination.
　Jpn. J. Cardiovasc. Surg. 33: 193-196 (2004)

Successful Management of Infected Superficial Femoral Aneurysm Caused by Citrobacter koseri 　　H. Nishida, et al.…197

Successful Management of Infected Superficial Femoral Aneurysm Caused by Citrobacter koseri (Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Japan) Hirofumi Nishida Yoshiharu Takahara Kenji Mogi Manabu Sakurai A 77-year-old man with diabetes mellitus and hypertension presented with acute onset of pain and swelling of the right thigh. Physical examination showed a pulsatile mass in the mid-portion of the right thigh. Computed tomography revealed the presence of a 7-cm diameter aneurysm at superficial femoral artery with gas shadow around the aneurysmal wall. A diagnosis of infected superficial femoral aneurysm was made and emergency surgery was undertaken. The total resection of the aneurysmal wall, debridement of necrotic tissues including part of sartorius and quadriceps muscles were done. Femoro-popliteal bypass through subcutaneous route using a 6-mm diameter Dacron prosthesis was used as the mean of vascular reconstruction procedure. Citrobacter koseri was cultured from the infected aneurysmal wall. The antibiotic treatment was continued for total of 2 weeks. Although additional debridement was required, the patient was amkulabony when discharged on the 37th postoperative day. Jpn. J. Cardiovasc. Surg. 33: 197-200 (2004)

Successful Revascularization Using Cardiopulmonary Bypass in a Case of Angina Abdominalis due to Acute Superior Mesenteric Arterial Embolism 　　Y. Nakayama, et al.…201

Successful Revascularization Using Cardiopulmonary Bypass in a Case of Angina Abdominalis due to Acute Superior Mesenteric Arterial Embolism

(Department of Cardiovascular Surgery, Ohsumi Kanoya Hospital, Kanoya, Japan)

Yoshihiro Nakayama Noritoshi Minematsu Kiyokazu Koga

An 89-year-old man with a past history of paroxysmal atrial fibrillation was urgently admitted to our hospital because of sudden-onset pain in the left forearm. The pulse of the left brachial artery had disappeared. Angiography demonstrated left brachial artery occlusion due to a thrombus. The day after an emergency thrombectomy, abdominal pain occurred after eating. Enhanced computed tomography and aortography revealed that the superior mesenteric artery (SMA) was occluded with collateral circulation from the inferior mesenteric artery (IMA). Under a diagnosis of angina abdominalis, the bypass procedure, using a saphenous vein graft (SVG) from the abdominal aorta to the SMA, was carried out under the support of cardiopulmonary bypass. To maintain antegrade alignment of the SVG, the SVG was anastomosed proximally to the infrarenal abdominal aorta. Severe atherosclerotic changes were observed in the main trunk of the SMA. However, no intestinal necrosis occurred because of the well-developed collateral flow from the IMA. The mechanism of angina abdominalis is probably due to thromboembolism in the SMA which had preexisting stenotic organic lesions.
　Jpn. J. Cardiovasc. Surg. 33: 201-204 (2004)

Emergency Reoperation for Vein Graft Rupture Caused by PCI Failure 　　N. Sasahashi and K. Ueyama…205

Emergency Reoperation for Vein Graft Rupture Caused by PCI Failure

(Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan)

Nozomu Sasahashi Koji Ueyama

A 68-year-old woman on chronic hemodialysis was admitted to our hospital for further evaluation because of recurrent angina 14 months after coronary bypass surgery (left internal thoracic artery-left anterior descending artery (LITA-LAD), gastro-epiploic artery-4 posterior descending artery (GEA-4PD), saphenous vein graft-＃9-＃14 sequential (SVG-＃9-＃14 sequential)). On coronary angiography, a localized 90% stenosis of the vein graft was present at the anastomosis with the diagonal branch of the native coronary artery. Although the lesion was relieved with a 5mm balloon catheter inflated to 14 atmospheres, contrast injection demonstrated extravasation of dye into the pericardial space, indicating vein graft rupture. Repositioning the inflated balloon across the rupture site for hemostasis was unsuccessful, and the patient was transferred to the operating room. Emergency reoperation was accomplished through a left lateral thoracotomy without cardiopulmonary bypass. Although hemorrhage was not noted at the rupture site, the vein graft was ligated at the proximal and distal portions of the rupture, followed by a new vein graft bypass. Postoperative cardiac catheterization clearly demonstrated the patent graft. Although localized hypokinesis was observed in the lateral wall on postoperative echocardiography, the left ventricular ejection fraction was 67%, her activity level was good, and she had no angina.
　Jpn. J. Cardiovasc. Surg. 33：205-207 (2004)

A Case of Severe Aortic Stenosis Accompanied by Porcelain Aorta Treated with an Apicoaortic Valved Conduit 　　N. Saitoh, et al.…208

A Case of Severe Aortic Stenosis Accompanied by Porcelain Aorta Treated with an Apicoaortic Valved Conduit

(Department of Cardiovascular Surgery, Tachikawa Medical Center, Nagaoka, Japan)

Norihiko Saitoh Kazuo Yamamoto Satoshi Tanaka

Chizuo Kikuchi Tsutomu Sugimoto Shigetaka Kasuya

The patient was a 70-year-old woman with severe aortic stenosis and familial hyperlipidemia which was diagnosed in 1994. The patient was admitted as an emergency case due to syncope in 2002. According to ultrasound cardiography (UCG), the pressure gradient of the aortic valve was 120.7mmHg, and the diameter of the aortic valve annulus was 16.7mm. Computed tomography showed porcelain aorta from the annulus of aortic valve to the ascending aorta. On cardiac catheterization, the pressure gradient was 96mmHg, AVA was 0.4cm², and the ejection fraction was 38.7%. Since these findings suggested that conventional AVR was difficult, thoracotomy was performed at the left 5th intercostal level, and apicoaortic valved conduit (valved graft: SJM19HP, Intergard 22mm＋Medtronic apical LV connector) was implanted. Postoperative cine MRI showed that most of the cardiac output (87%, 3.29l/min) flowed through the conduit, with the flow via the aortic valve accounting for 13%, 0.51l/min. This surgical procedure can be an effective alternative when conventional AVR is difficult.
　Jpn. J. Cardiovasc. Surg. 33: 208-212 (2004)

A Modified Procedure Using Branched Graft as Inflow for Leg Revascularization in a Case of Acute Type A Aortic Dissection Complicated with Leg Ischemia 　　S. Takeuchi, et al.…213

A Modified Procedure Using Branched Graft as Inflow for Leg Revascularization in a Case of Acute Type A Aortic Dissection Complicated with Leg Ischemia

(Division of Cardiovascular Surgery, Narita Red Cross Hospital, Narita, Japan and Department of Cardiovascular Surgery, Funabashi Municipal Medical Center*, Funabashi, Japan)

Shigeyasu Takeuchi* Hisanori Fujita Nobuyuki Nakajima

A 32-year-old man with severe back pain and cold, pulseless bilateral lower extremities was admitted. Enhanced CT scan revealed acute type A aortic dissection and the true lumen was severely compressed or occluded at the level of the abdominal aorta. Emergency simultaneous graft replacement of the ascending aorta and aortic arch was performed under deep hypothermic circulatory arrest, antegrade selective cerebral perfusion in addition to the elephant trunk technique. Although distal anastomosis was constructed only to the true lumen, leg ischemia persisted. Therefore, a new modified procedure applying a branched graft used for antegrade systemic perfusion as inflow and conventional axillo-bifemoral bypass graft was anastomosed to restore adequate circulation to the lower extremities. In the treatment of acute type A aortic dissection complicated with leg ischemia, the modified technique we employed is a simple and feasible method for leg revascularization in cases in which malperfusion to the leg persists in spite of complete of aortic repair.
　Jpn. J. Cardiovasc. Surg. 33: 213-215 (2004)

Successful Surgical Repair of Left Main Coronary Artery Total Occlusion with Aortitis Syndrome 　　H. Misumi, et al.…216

Successful Surgical Repair of Left Main Coronary Artery Total Occlusion with Aortitis Syndrome

(Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan)

Hiroyasu Misumi Masamitsu Murata Yoshihiro Yoshimura

Akira Yamazaki Ichiro Ideta Hideyuki Uesugi

Yasuhiro Shimokawa Tohitsu Hirayama

We report the successful repair of left main coronary artery obstruction with aortitis syndrome. She was a 39-year-old woman and was admitted to Saiseikai Kumamoto Hospital because of angina pectoris. Her bilateral radial artery pulsation was not palpable. Total occlusion of the left main coronary artery (LMT) and bilateral subclavian artery was detected by angiography. Patch enlargement of the LMT was performed using a Distaflo (Impra Carbon PTFE) graft. Postoperative coronary angiography showed an adequate LMT diameter and sufficient blood flow.
　Jpn. J. Cardiovasc. Surg. 33: 216-219 (2004)

Successful Surgical Treatment of Ruptured Abdominal Aortic Aneurysm Following Stanford Type B Acute Aortic Dissection 　　T. Kobayashi, et al.…220

Successful Surgical Treatment of Ruptured Abdominal Aortic Aneurysm Following Stanford Type B Acute Aortic Dissection

(Department of Cardiovascular Surgery, Saiseikai-Shimonoseki General Hospital, Shimonoseki, Japan)

Toshiro Kobayashi Kensuke Sakata Kenji Hayashi

Yurio Kobayashi

A 72-year-old man presented with back pain and 3 days after admission, chest and abdominal CT scanning revealed the existence of infrarenal abdominal aortic aneurysm with Stanford type B acute aortic dissection and hemorrhage in the retroperitoneal space. The maximum diameter of the abdominal aortic aneurysm was 60mm. After treating with anti-hypertensive therapy under restrictive observation because of the patient's stable general condition, surgery was performed 45days after admission. The dissection extended into the abdominal aortic aneurysm and all visceral arteries branched from the true lumen. The presence of thrombus in the preperitoneal space suggested a ruptured abdominal aortic aneurysm. Abdominal aortic aneurysm was replaced with a Y shaped graft and proximal anastomoses was performed with fenestration to prevent rupture of the proximal dissecting aorta. We report a rare case of ruptured abdominal aortic aneurysm following Stanford type B acute aortic dissection, which was operated on in the chronic stage. The patient is doing well.
　Jpn. J. Cardiovasc. Surg. 33: 220-223 (2004)

Redo Off-Pump Coronary Artery Bypass Grafting through Left Thoracotomy Using the Aortic Connector for Proximal Graft Anastomosis on the Descending Aorta 　　Y. Misawa, et al.…224

Redo Off-Pump Coronary Artery Bypass Grafting through Left Thoracotomy Using the Aortic Connector for Proximal Graft Anastomosis on the Descending Aorta

(Department of Cardiovascular Surgery, Oohara Medical Center, Fukushima, Japan and Department of Cardiovascular Surgery, Fukushima Medical University School of Medicine*,**, Fukushina, Japan)

Yukitoki Misawa* Kenichi Hagiwara Hitoshi Yokoyama**

A 76-year-old man who had undergone primary coronary operation through a median sternotomy 9 years previously presented with recurrent angina. Preoperative angiography revealed 90% stenosis of the circumflex coronary artery and left subclavian artery. Two saphenous vein grafts (SVG) placed in the previous operation were patent. Redo off-pump CABG was performed through a left thoracotomy approach. The proximal end of the new SVG was connected to the descending thoracic aorta using the St. Jude Medical aortic connector system. The distal anastomosis to the obtuse marginal branch was performed on a beating heart. The postoperative course was uneventful. This case suggested that, in cases requiring the proximal graft anastomosis on the descending aorta, the application of the aortic connector system can be a useful strategy, helping to facilitate the proximal anastomosis and avoid complications associated with the aortic partial-clamping on the descending aorta.
　Jpn. J. Cardiovasc. Surg. 33: 224-226 (2004)