Japanese Journal of Cardiovascular Surgery Vol.33, No.5

Originals

Long-Term Results of Patchplasty for True Thoracic Aortic Aneurysm and the Effectiveness of Open Stents in Recurring Cases 　　I. Morita, et al.……309

Long-Term Results of Patchplasty for True Thoracic Aortic Aneurysm and the Effectiveness of Open Stents in Recurring Cases

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

Ichiro Morita Eishun Shishido Hisao Masaki

Atsuhisa Ishida Atsushi Tabuchi Yoshiaki Fukuhiro

Souhei Hamanaka Hiroshi Kubo Kazuo Tanemoto

We reviewed 24 cases of patchplasty for true thoracic aortic aneurysm performed in our hospital up to July 2001. The size of the aneurysm in the ascending aorta was 6.0cm (1case), and the mean size in the aortic arch was 2.5±0.5cm (4cases), that in the distal arch was 4.7±1.7cm (11cases), and that in the descending aorta was 3.7±0.5cm (8cases). The hospital mortality rate was 12.5% (3 patients out of 24). The causes of death were multiple organ failure, cerebral bleeding and sepsis. In the long-term results, 2 patients had recurrence, but there were no late deaths in relation to the aneurysmal recurrence. We performed open stent operations for severe adhesion and pulmonary dysfunction in the aneurysmal recurrence cases. The postoperative course of these cases was uneventful. The open stent was useful for the treatment of the aneurysmal recurrence in the distal arch.
　Jpn. J. Cardiovasc. Surg. 33: 309-313 (2004)

Intra-Abdominal Pressure Monitoring after Ruptured Abdominal Aortic Aneurysm Surgery 　　S. Isoda, et al.……314

Intra-Abdominal Pressure Monitoring after Ruptured Abdominal Aortic Aneurysm Surgery

(Department of Cardiovascular Surgery, Saisei-kai Yokohamashi Nanbu Hospital, Yokohama, Japan, Cardiovascular Division^*1, Emergency Center^*2, Yokohama City University School of Medicine, Medical Center, Yokohama, Japan and First Department of Surgery, Yokohama City University School of Medicine^*3 Yokohama, Japan)

Susumu Isoda Masato Okita Akira Sakamoto

Tamitaro Soma Kiyotaka Imoto^*1 Shin-ichi Suzuki^*1

Keiji Uchida^*1 Nobuyuki Kosuge^*2 Yoshinori Takanashi^*3

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (p＝0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (p＝0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (p＝0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (p＝0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (p＝0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (p＝0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (p＝0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.
　Jpn. J. Cardiovasc. Surg. 33: 314-318 (2004)

Evaluation of the Palmaz Stent in Iliac Artery Stenosis Using Intravascular Ultrasound 　　H. Kumakura, et al.……319

Evaluation of the Palmaz Stent in Iliac Artery Stenosis Using Intravascular Ultrasound

(Internal Medicine and Cardiovascular Surgery*, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Gunma, Japan)

Hisao Kumakura Hiroyoshi Kanai Shuichi Ichikawa

Takashi Ogino* Tetsuya Koyano* Kito Mitsui*

We determined cross sectional area of stent and lumen of iliac arterial lesions before and after deployment of Palmaz stents using intravascular ultrasound (IVUS). Stent deployment was performed in 43 patients with 47 lesions. Cross sectional images were recorded using IVUS in the proximal (P), center (C), and distal portion (D) of the stent in the iliac lesions before, immediately after, and 6 months after the deployment of stent. The initial success rate was 100%. Ultrasound images were analyzed for lumen, intra-stent and intimal proliferation area. The lumen area dilated significantly from 9.9±7.1mm² to 32.7±9.4 after the stent deployment. The intra-stent cross sectional area right after the treatment did not show any difference among the 3 portions. The mean stent area after 6 months was 32.8±8.4mm², without significant stent recoil. The lumen (＝intra-stent) area after stent deployment were P: 33.8±9.7mm², C: 30.9±9.0, and D: 32.7±8.6. The lumen of the center portion had a tendency to be smaller than that of the proximal or distal portions. After 6 months, the intra-stent area was P: 33.5±9.2mm², C: 31.5±7.7, and D: 33.3±8.3 and the lumen area was P: 31.3±10.4mm², C: 28.2±8.9, and D: 29.4±10.5. Stent recoil was not observed but minimal dilatation was noted in the center and distal portions. The lumen area after 6 months became smaller than that immediately after the treatments due to intimal proliferation and stent deformation. The lumen area in the center portion had a tendency to be smaller than that of the proximal portion. The rates of change in the lumen area were P: －6.7±5.6%, C: －9.8±6.4% and D: －12.4±9.9. This showed a tendency for the lumen of the distal portion to be smaller than that of the proximal portion due to intimal proliferation. The intimal proliferation rates showed a tendency to be higher toward distal sites, but the narrowest portion in the stent was its center. The long-term patency diagnosed by angiography was 92.3% in 6 months and 89.5% in 12 and 24 months. IVUS is useful for evaluation of iliac stent deployment. The Palmaz stent was a very effective treatment for the iliac arterial lesions, protecting against vascular recoil.
　Jpn. J. Cardiovasc. Surg. 33: 319-324 (2004)

Usefulness of Lower Ministernotomy in Aortic Valve Replacement (AVR) by Minimary Invasive Cardiac Surgery (MICS) 　　S. Shioguchi, et al.……325

Usefulness of Lower Ministernotomy in Aortic Valve Replacement (AVR) by Minimary Invasive Cardiac Surgery (MICS)

(Department of Cardiovascular and Thoracic Surgery, Koshigaya Hospital, Dokkyo University School of Medicine, Koshigaya, Japan)

Souichi Shioguchi Yoshihito Irie Nobuaki Kaki

Masahito Saito Shuichi Okada Koyu Tanaka

Takao Imazeki

Upper ministernotomy is frequently selected in aortic valve replacement by minimary invasive cardiac surgery. However, retrograde cardioplegia cannulae cannot be inserted to some sites. CT examinations in our department revealed that lower ministernotomy can be used for surgery of the aortic valve in many Japanese cases. The usefulness of 2 approaches was examined in 68 cases with aortic valve disease who received aortic valve replacement by minimary invasive cardiac surgery from January 1997 to March 2002: Those who received upper ministernotomy (U group) and those who received lower ministernotomy (L group). Retrograde cardioplegia is frequently used in aortic valve replacement for myocardial protection. Those in the L group showed effectiveness in myocardial protection and in securing the operation field except in cases who were switched to full sternotomy. In the L group, the MAZE operation was performed and no significant differences were observed in aortic cross-clamping time, artificial cardiorespiratory time, operation time, bleeding amount and other factors. Lower ministernotomy was more effective than upper ministernotomy in myocardial protection by retrograde cardioplegia and securing the operation field in aortic valve replacement by minimally invasive cardiac surgery.
　Jpn. J. Cardiovasc. Surg. 33: 325-328 (2004)

Case Reports

A Case of Cardiac Infiltrating Lipoma in the Interatrial Septum 　　H. Nishida, et al.……329

A Case of Cardiac Infiltrating Lipoma in the Interatrial Septum

(Division of Cardiovascular Surgery, Kimitsu Chuo Hospital, Kisarazu, Japan)

Hirofumi Nishida Yoshio Sudou Hideo Ukita

Nobuyuki Nakajima

A 75-year-old woman presented with chest pain on exertion. Cardiac catheterization revealed double vessel coronary artery disease. Echocardiographic examination showed the presence of an abnormal mass in the interatrial septum without any flow velocity signal within the mass. She was scheduled for elective coronary artery bypass grafting. The lesion appeared as a homogeneous mass on CT scan, with an attenuation coefficient of －122 Hounsfield units, suggestive of lipoma. A T1-weighted MRI scan demonstrated that the signal intensity of the interatrial mass corresponded to that of fatty tissue. On surgery with cardiopulmonary bypass a large mass was found to involve the right atrial wall, the interatrial sulcus and the interatrial septum. The mass could not be resected completely, because it adhered strongly to the septal myocardium. On histological examination, the tumor was composed of mature fatty tissues, was not encapsulated and was diagnosed as infiltrating lipoma. The postoperative course was uneventful. CT, MR imaging and color Doppler ultrasonography were very useful in making a tissue-specific diagnosis.
　Jpn. J. Cardiovasc. Surg. 33: 329-332 (2004)

A New Technique of Left Atrial Spiral Plication for Giant Left Atrium 　　H. Doi, et al.……333

A New Technique of Left Atrial Spiral Plication for Giant Left Atrium

(Department of Cardiovascular Surgery, Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan)

Hirosato Doi Hiroshi Sugiki Junshi Yasuike

Chikara Shiiku, Youhei Ohkawa Kenji Sugiki

Takemi Ohno

A new technique of left atrial plication (LAP) for giant left atrium (GLA) resulting from mitral regurgitation (MR) is reported. A 66-year-old man was found to have NYHA class III resulting from severe MR, mild TR and GLA with a left atrial diameter (LAD) of 107mm on echocardiogram. Chest X-ray showed the cardiothoracic ratio (CTR) to be 92%, and the right side CTR was 88.4%. Surgery was performed under general anesthesia with endotracheal intubation. Under cardiac arrest established by antegrade and retrograde cardioplegia, mitral repair was performed first through a superior transseptal approach. Left atrial resection was continued paralell to the mitral posterior annulus and to the right side wall of the left atrium, following the right side resection. Simultaneously the left atrial wall was incised 3 to 4 cm in width all the way along the resection line and it was closed by a running suture of 3-0 prolene. The continuous line of the left atrial plication formed a spiral shape. A prominent portion of the atrial septum resulted from the LAP and the right atrial wall was also resected and plicated. The postoperative course was uneventful, and the postoperative CTR reduced to 71% with a right side CTR of 54.4% with reduction of LAD to 67mm on ultrasound cardiogram (UCG). This spiral LAP was considered more effective to reduce all dimensions of the giant left atrium dilated in all directions in comparison with other LAP methods previously reported.
　Jpn. J. Cardiovasc. Surg. 33: 333-336 (2004)

Tricuspid and Mitral Valve Replacement in a Patient with Atrioventricular Discordance Long after Functional Biventricular Repair 　　K. Aoki, et al.……337

Tricuspid and Mitral Valve Replacement in a Patient with Atrioventricular Discordance Long after Functional Biventricular Repair

(Department of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medicine, Niigata, Japan)

Kenji Aoki Hiroshi Watanabe Yuko Tosaka

Jun-ichi Hayashi

In atrioventricular (AV) discordance, a morphologic tricuspid valve functioning as a systemic AV valve often becomes incompetent and needs to be replaced. However, mitral valve replacement concomitant with tricuspid valve replacement is unusual in the disease. Here, we report a case of successful double AV valve replacement long after functional biventricular repair in AV discordance. A 32-year-old man with AV discordance was admitted with orthopnea. He had undergone the Rastelli procedure at age 10 and removal of the deteriorated conduit valve at age 24. Preoperative examinations revealed not only tricuspid but also mitral regurgitation. Both deteriorated valves were replaced with mechanical valves. In AV discordance after Rastelli procedure, a non-valved conduit may accelerate mitral deterioration because pulmonary hypertension from tricuspid regurgitation increases the afterload of the pulmonary ventricle.
　Jpn. J. Cardiovasc. Surg. 33: 337-340 (2004)

Radiofrequency Maze Ablation in a Beating Heart with Cardiomyopathy 　　T. Ushijima, et al.……341

Radiofrequency Maze Ablation in a Beating Heart with Cardiomyopathy

(Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Maizuru, Japan)

Teruaki Ushijima Yoshitaka Ito Yoshitaka Demura

A 67-year-old woman suffering from chronic atrial fibrillation and cadiomyopathy was transferred to our hospital for treatment of a left atrial thrombus. Echocardiography demonstrated the thrombus attached to the left atrial appendage, left ventricular dilatation and low ejection fraction. Removal of the thrombus and radiofrequency Maze ablation were performed simultaneously under beating heart cardiopulmonary bypass. The patient showed no impairment of left ventricular function perioperatively and regained normal sinus rhythm.
　Jpn. J. Cardiovasc. Surg. 33: 341-343 (2004)

A Case of DeBakey Type II Aortic Dissection with Respiratory Tract Compression 30 Years after Open Aortic Commissurotomy 　　O. Namura, et al.……344

A Case of DeBakey Type II Aortic Dissection with Respiratory Tract Compression 30 Years after Open Aortic Commissurotomy

(Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan and Department of Cardiovascular Surgery, Saiseikai Niigata Daini Hospital*, Niigata, Japan)

Osamu Namura Hisanaga Moro* Yuko Tosaka

Masakazu Sogawa Jun-ichi Hayashi

A 43-year-old man visited another hospital because of dry cough and dyspnea in a supine position after having experienced chest pain about 1 month prior to his visit. He had undergone open aortic commissurotomy and ligation of the ductus arteriosus due to congenital bicuspid valve aortic stenosis and patent ductus arteriosus at age 13. CT scan showed a dissected giant aortic aneurysm (12.0cm in diameter) of the DeBakey Type II which compressed surrounding organs, such as his trachea, bilateral main bronchus, superior vena cava, and right main pulmonary artery. Echocardiograms revealed severe aortic stenosis and a dissecting ascending aortic aneurysm. The patient was admitted to our hospital and an urgent operation was performed. Under cardiopulmonary bypass with selective cerebral perfusion, a replacement of the aortic root and the ascending-arch aorta with the inclusion technique was performed. Postoperatively, the patient suffered from ventilatory disturbance under mechanical ventilation. CT scan showed a giant aneurysmal sac containing a hematoma in the perigraft space and the false lumen of the aneurysmal wall and remaining tracheobronchial compression. A reoperation was performed for removal of the hematoma and plication of the aneurysmal sac. The subsequent postoperative course was good. The patient was weaned from mechanical ventilation at 12 days and discharged at 67 days after the initial operation. Histologically, the resected aortic wall showed cystic medial necrosis.
　Jpn. J. Cardiovasc. Surg. 33: 344-347 (2004)

A Case of One-Stage Operation for Brachiocephalic Aneurysm and Aortic Regurgitation Associated with Aortitis Syndrome 　　H. Morita, et al.……348

A Case of One-Stage Operation for Brachiocephalic Aneurysm and Aortic Regurgitation Associated with Aortitis Syndrome

(Department of Cardiovascular Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan and Department of Cardiovascular Surgery, Hiroshima City Hospital*, Hiroshima, Japan)

Hideki Morita Hideo Yoshida* Toru Morimoto

Teiji Jinno Mamoru Tago Masataka Yamane

A 31-year-old woman had an aneurysm of the brachiocephalic artery and aortic regurgitation due to aortitis syndrome. As C-reactive protein (CRP) levels were high (27.5mg/dl), steroid therapy was initiated. After CRP became negative, the brachiocephalic aneurysm was repaired using a GELWEAVE^® Y-graft, and the aortic valve was replaced with an ATS^® mechanical valve. Regional cerebral oxygenation (rSO2) was monitored during the operative period. The level of rSO2 did not change during the period when the brachiocephalic artery was clamped, resulting in no cerebral damage after the operation. Horner’s syndrome appeared after the operation but the symptoms gradually improved spontaneously. A mechanical valve was chosen because the patient did not want to undergo a reoperation. No cerebrovascular event occurred after the operation and the patient was discharged on the 28th postoperative day.
　Jpn. J. Cardiovasc. Surg. 33: 348-351 (2004)

A Case of Giant Coronary Artery Aneurysm in the Right Atrium Associated with a Right Coronary-Right Atrial Fistula 　　M. Oshiumi, et al.……352

A Case of Giant Coronary Artery Aneurysm in the Right Atrium Associated with a Right Coronary-Right Atrial Fistula

(Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan and Division of Cardiology, Sasaki Hospital*, Saitama, Japan)

Motohiro Oshiumi Kazuhiro Hashimoto Hiroshi Okuyama

Ryuichi Nagahori Gen Shinohara Masamichi Nakano*

Coronary artery fistula is an unusual congenital anomaly, particularly in association with coronary aneurysm. In the present case, a right coronary fistula leading to the right atrium was associated with a giant coronary aneurysm. There have only been 3 such cases reported in the literature. Since both the aneurysm and the fistula were completely thrombosed, no heart murmur was detected and the patient was initially diagnosed as having an intracardiac tumor by echocardiography.
　Jpn. J. Cardiovasc. Surg. 33: 352-355 (2004)

A Case of Subclavian-Subclavian Artery Bypass Grafting for Relief of Left Subclavian Artery Occlusion in a Patient with Coronary Artery 　Bypass Grafting Using a Left Internal Mammary Artery Graft 　　K. Takeuchi, et al.……356

A Case of Subclavian-Subclavian Artery Bypass Grafting for Relief of Left Subclavian Artery Occlusion in a Patient with Coronary Artery Bypass Grafting Using a Left Internal Mammary Artery Graft

(Department of Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka, Japan and Department of Cardiovascular Surgery, Cardiovascular Center, Omura Municipal Hospital*, Omura, Japan)

Kazuma Takeuchi Katsuhiko Nakamura* Noritsugu Morishige

Ryuichi Shibano Ryuji Zaitsu Hidehiko Iwahashi

Yoshio Hayashida Tadashi Tashiro

A 65-year-old man had undergone coronary artery bypass grafting (CABG) using a left internal mammary artery graft 3 years and 5 months previously. Anginal pains recurred due to an occlusion of the left subclavian artery. A subclavian-subclavian artery bypass was performed using 8 mm e-PTFE graft with rings and the results were excellent. This grafting procedure appears to be a safe and satisfactory reperfusion technique, and therefore we recommend its use in patients requiring CABG.
　Jpn. J. Cardiovasc. Surg. 33: 356-358 (2004)

Salvage Therapy with Non-Heparinized Extracorporeal Life Support for Massive Lung Hemorrhage after Pulmonary Thromboembolectomy 　　M. Matsubara, et al.……359

Salvage Therapy with Non-Heparinized Extracorporeal Life Support for Massive Lung Hemorrhage after Pulmonary Thromboembolectomy

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

Muneaki Matsubara Yuji Hiramatsu* Tomohiro Imazuru*

Masataka Sato Chiho Tokunaga Mio Noma*

Tomoaki Jikuya* Yuzuru Sakakibara*

Lung hemorrhage associated with pulmonary reperfusion injury is a rare but lethal condition. We presented a case salvaged by non-heparinized extracorporeal life support for massive lung hemorrhage after pulmonary thromboembolectomy. Sub-acute pulmonary thromboembolism with a floating right atrial thrombus was diagnosed in 63-year-old woman by computed tomography and echocardiography. An emergency pulmonary thromboembolectomy was performed using cardiopulmonary bypass and moderate hypothermia. Immediately after reperfusion, extraordinary lung hemorrhage occurred and continued. We decided to take over the standard cardiopulmonary bypass with a non-heparinized extracorporeal life support system. Fortunately, hemostasis of the lung hemorrhage was completely secured within 12h, and the extracorporeal life support was terminated at 20h after the surgery. The patient was extubated at 48h after the surgery, and was discharged after the insertion of an inferior vena cava filter for a floating deep venous thrombus. Although the necessity, efficacy and risk of the non-heparinized extracorporeal life support should be clarified, we conclude that it could be the treatment of choice for life threatening lung hemorrhage associated with pulmonary reperfusion injury.
　Jpn. J. Cardiovasc. Surg. 33: 359-362 (2004)

Ross Operation for Prosthetic Aortic Valve Endocarditis with Paravalvular Abscess 　　M. Mohri, et al.……363

Ross Operation for Prosthetic Aortic Valve Endocarditis with Paravalvular Abscess

(Department of Cardiovascular Surgery, Sakakibara Hospital, Okayama, Japan and First Department of Surgery, Showa University*, Tokyo, Japan)

Makoto Mohri* Takato Hata Yoshimasa Tsushima

Mitsuaki Matsumoto Hidenori Yoshitaka Souhei Hamanaka

Satoru Ohtani

An 18-year-old man underwent a Ross operation for the treatment of prosthetic aortic valve endocarditis with extensive perivalvular tissue destruction. Postoperatively, he developed poststernotomy methicillin-resistant Staphylococcus aureus mediastinitis, which was treated with one-staged irrigation, debridement and omental transfer. After 3 years of follow-up, he is doing well without any sign of infection or a graft failure.
　Jpn. J. Cardiovasc. Surg. 33: 363-365 (2004)

A Case of Acute Hydronephrosis Caused by a Common Iliac Aneurysm 　　S. Okumura and J. Okawara……366

A Case of Acute Hydronephrosis Caused by a Common Iliac Aneurysm

(Department of Cardiovascular Surgery, Shiga National Hospital, Yokaichi, Japan)

Satoru Okumura Jun Okawara

A 72-year-old man presented with acute abdominal pain from the left lateral to the left lower quadrant. His medical history included hypertension and hyperthyroidism. Four days after the onset, abdominal computed tomography revealed left hydronephrosis and a solitary left common iliac aneurysm obstructing the left ureter. The irregularity of the pelvic border made us suspect injuries to the left pelvis. We diagnosed acute left hydronephrosis, caused by the ureteral obstruction due to the left common iliac aneurysm. The aneurysm was replaced with a prosthetic graft to remove the pressure on the urinary tract. We did not try to dissect the left ureter from the aneurysmal wall. The postoperative course was uneventful, and the ureter recovered from the obstruction.
　Jpn. J. Cardiovasc. Surg. 33: 366-369 (2004)