|Keiichi Furubayashi||Masayoshi Nishimoto||Hitoshi Fukumoto|
|Minimally Invasive Cardiac Surgery (MICS) for Double Valve Replacement (DVR)|
|Minimally invasive cardiac surgery (MICS) for treating valvular disease was introduced in our division in July 1997, and we have treated a total of 236 cases by July 2002. Among the various types of surgical treatment, there were 21 cases (M-group) of double valve replacement (DVR) to treat combined valvular disease. There had been 8 cases (F-group) of DVR by means of conventional full sternotomy during the period from January 1990 to June 1997, before the introduction of MICS. A comparison of the results of these surgical treatments yielded the following results. There were no differences in operation time and blood loss during the operations between the 2 groups, whereas the aortic cross clamp time and cardiopulmonary bypass time were significantly longer in the M-group than the F-group (M-group: 189±6 and 228±7 min; F-group: 132±18 and 183±16 min, respectively). There were significantly more cases of concomitant maze operation in the M-group than in the F-group. There were no differences in the durations of postoperative intubation or ICU stay. The days required from operation to starting walking were significantly shorter in the M-group compared to in the F-group (M-group: 2.4±0.2 days; F-group: 3.3±0.2 days), while there were no differences in the postoperative hospitalization periods. There were no major postoperative complications, and 1 case each there was 1 death in each group during the hospitalization period. Although the aortic cross clamp time and cardiopulmonary bypass time were longer in the M-group than in the F-group, the postoperative course and surgical outcome were good. So MICS for DVR was considered acceptable. In addition, MICS was thought to provide high patient satisfaction with regard to cosmesis or thoracic fixation, although early discharge from the hospital, which was possible in cases of single valve MICS, was not obtained.
Jpn. J. Cardiovasc. Surg. 34: 5-8 (2005)
|Long-Term Results of Open Heart Surgery in Hemodialysis Patients―CABG vs. Valve Replacement―|
|We evaluated 30 patients who required
hemodialysis (HD) before open heart surgery between January 1990
and September 2003. The patients were divided into 2 groups according
to surgical procedure: 20 patients underwent coronary artery
bypass grafting (CABG group: 14 men and 6 women, mean age, 63
years), and 10 patients underwent valve replacement (VR group:
6 men and 4 women, mean age, 56 years). The mean duration of
HD in the CABG group was significantly shorter than that in the
VR group (67 months:121 months, p=0.02). The actual survival
rate was calculated by Kaplan-Meier's method. No patient was
lost to follow-up. There were 3 hospital deaths in the CABG group
(cerebral infarction, arrhythmia, and mediastinitis), and 2 hospital
deaths in the VR group (gangrenous cholecystitis and sepsis).
There were also 5 late deaths in the CABG group (acute subdural
hematoma, pneumonia, AMI, heart failure and gastric cancer) and
4 deaths in the VR group (uterus cancer, 2 intracerebral hemorrhages
and PVE). All cardiac event deaths in the CABG group had undergone
CABG only with vein grafts. The 4-year actuarial survival rates
were 56% (n=5) in the CABG group with a mean follow-up
period of 29 months (max 156 months), and 47% (n=3) in
the VR group with a mean follow-up period of 35 months (max 131
months). There are 3 points to improve the prognosis of open
heart surgery in hemodialysis patients: control of postoperative
infection in both groups, prevention of cardiac events in the
CABG group and careful anticoagulation therapy in the VR group.
Jpn. J. Cardiovasc. Surg. 34: 9-13 (2005)
|Surgical Site Infection by Methicillin-Resistant Staphylococcus aureus after Cardiovascular Operations: An Outbreak and Its Control|
|We encountered 15 cases of surgical
site infection (SSI) by Methicillin-resistant Staphylococcus
aureus (MRSA) among 153 patients who underwent a cardiovascular
operation in 2000. SSIs consisted of 5 mediastinal infections,
9 surface wound infections and 1 artificial graft infection after
an abdominal aortic surgery. All infected cases had been operated
on between June and December 2000. Eighty-three cases, which
underwent cardiovascular operations during this period, were
divided into SSI or no-SSI groups and their clinical data were
analyzed. The data included age, gender, preoperative diabetes,
urgency, preoperative usage of a device like Swan-Ganz catheter
or IABP, preoperative albumin level, preoperative physical state
by ASA score, National Nosocominal Infections Surveillance index,
duration of operation, usage of a cardiopulmonary bypass, duration
of bypass, type of operation, and number of distal anastomoses
in CABG operations. Multivariate analysis showed gender (male),
diabetes, and emergency operation as independent risk factors
for the incidence of SSI by MRSA. One patient, who suffered a
mediastinal infection after CABG, had confirmed as demonstrating
the colonization of MRSA in sputum preoperatively. Microbiological
screening of medical staff showed 2 of the 6 surgical doctors
and 3 of the 25 ward nurses exhibited colonization with MRSA.
DNA analysis of MRSA, harvested from 5 infected patients, indicated
at least 2 strains of MRSA and 1 of the 2 strains was identical
to the MRSA that was detected in a doctor. We applied prophylactic
measures with reference to the guideline for prevention of surgical
site infection announced by CDC in 1999, which included the following:
routine work-up of MRSA-colonization, and treatment of all MRSA
colonized patients and those undergoing emergency operations
with Mupirocin. Preoperative patients were isolated from MRSA-infected
or colonized patients. MRSA-colonized surgical personnel were
treated with Mupirocin ointment. Cephazoline was administered
shortly before and after the operation as a prophylactic antibiotic.
Vancomycin was added to Cephazoline in patients with a history
of MRSA-colonization or infection. Through hand washing before
and after daily contact with patients was emphasised to all medical
staff. SSI surveillance conducted by an infection control team
was implemented. After the introduction of the prophylactic measurements,
one MRSA-SSI was observed among 113 cases who underwent a cardiovascular
operation between January and September 2001.
Jpn. J. Cardiovasc. Surg. 34: 14-20 (2005)
|A Surgical Approach to the Repair of a False Aneurysm in the Left Main Trunk, Using Transection of the Main Pulmonary Artery|
|A false aneurysm in a coronary anastomotic region is known to be an important complication after a modified Bentall procedure. We report a successful case of a 40-year-old woman in whom we performed repair of a false aneurysm in the left main trunk (LMT), using transection of the main pulmonary artery. The modified Bentall procedure and coronary artery bypass grafting (CABG) on the right coronary artery had been performed 6 years earlier, with diagnoses of Marfan syndrome, annuloaortic ectasia, aortic regurgitation, aortic dissection (DeBakey type II), and right ventricular infarction. The patient was admitted with a syncopal attack, and we diagnosed a false aneurysm in the anastomotic region of the left coronary artery. Repair of the LMT and CABG on the left anterior descending coronary artery with the left internal thoracic artery (LITA-RAD) was performed. For repair of the LMT, we used a surgical approach using transection of the main pulmonary artery to create a favorable surgical field.
Jpn. J. Cardiovasc. Surg. 34: 21-24 (2005)
|Endovascular Stent Grafting of a Perforated Descending Aorta Caused by Empyema|
|We performed endovascular stent grafting of a perforated descending aorta, caused by empyema after surgery for lung cancer , in a 75-year-old man. After diagnosing hemorrhage from a perforation of the proximal descending aorta, caused by left empyema, the perforation was repaired with a saphenous vein patch and a pectoralis major muscle flap. However, re-hemorrhage from the same lesion occurred 2 months postoperatively. Temporary hemostasis was achieved with gauze packing and he was transferred to our hospital for endovascular stent grafting. The infection did not resolve after fenestration, so the descending aorta was cropped out to the fenestration lesion. Therefore, endovascular stent grafting was performed on the same day. Postoperatively the bleeding stopped completely without any signs of graft infection, and he was transferred to another hospital on postoperative day 9. No re-hemorrhage or graft infection of the aortic perforative lesion occurred in the early postoperative period. However, the patient died of massive bleeding from the aorta wall of the proximal stump of the stent graft, caused by recurrence of the infection 2 months after the 2nd operation. In this situation, endovascular stent grafting provides the only chance of saving the patient’s life. If endovascular stent grafting is performed as a lifesaving procedure, meticulous operative technique is imperative.
Jpn. J. Cardiovasc. Surg. 34: 25-28 (2005)
|Tomokuni Furukawa||Shuji Kohata||Saihou Hayashi|
|Right Parasternal Vertical Approach for Tricuspid Valve Replacement in Repeated Cardiac Surgery|
|Median sternotomy is the most common approach used for repeated cardiac surgery, but it is associated with potential risks such as cardiac injury. Patients with valvular heart disease may be especially prone to these complications because of severe cardiomegaly and adherence of the heart to the posterior sternum. To avoid these risks, we began using a right thoracotomy approach, performed through a right parasternal vertical incision, which is better than the traditional right anterolateral thoracotomy, in selected patients. A 50-year-old woman who had undergone 3 previous cardiac operations at another hospital presented with remarkable cardiomegaly. We performed successful tricuspid valve replacement for tricuspid stenosis, through a right parasternal vertical incision. This approach provides excellent exposure of the tricuspid valve with minimal need for dissection. The right parasternal vertical incision has 3 main advantages over right anterolateral thoracotomy; first, it provides an excellent view of the right atrium underneath the wound; second, it allows for easy cannulation because of the position of the spine; and third, the skin incision is smaller. In conclusion, we think that the parasternal vertical incision is a better approach for repeated cardiac surgery than anterolateral thoracotomy because it provides a better operative view and an easier maneuver.
Jpn. J. Cardiovasc. Surg. 34: 33-36 (2005)
|Atrial Blood Cyst: A Rare Tumor in an Adult|
|A regular check-up in a 69-year-old man showed normal blood chemistry values, except for elevated value of liver enzymes and inflammatory reactions. A computed tomography scan (CT) of the abdomen revealed a normal appearance of the liver, pancreas and spleen, but incidentally showed a tumor in the right atrium. The tumor (a blood cyst which contained white thrombus) was successfully excised. Blood cysts of the heart are extremely rare in adults. These tumors are incidently found at autopsy on cardiac valves in approximately 50% of infants under 2 months of age. The blood cyst in this case arose from the right atrial wall, which is also quite rare.
Jpn. J. Cardiovasc. Surg. 34: 37-39 (2005)
|A Case of Aortic Valve Blood Cyst with CoA Complex|
|A2-month-old girl had been urgently seen on postnatal day 10 due to poor weight gain and tachypnea. Echocardiography showed congenital valvular aortic stenosis (AS), ventricular septal defect (VSD), atrial septal defect (ASD), and aortic valve dysplasia, but no cyst image was seen at the aortic valve level. Aortography revealed a dysplastic aortic valve along with coarctation of aorta (CoA) and patent ductus arterious (PDA). Balloon aortic valvotomy (BAV) was performed on day 53. Ballooning was satisfactory, but there was no change in gradient. Operation was performed on day 70 under a diagnosis of congenital AS and CoA complex. After cardiopulmonary bypass was established, the ascending aorta was transected. The blood cyst originated from the center of the anterior leaflet and was resected. The pressure gradient at the aortic valve decreased to 22.5mmHg. The patient was discharged 25 days after surgery.
Jpn. J. Cardiovasc. Surg. 34: 40-43 (2005)
|Pericardiectomy with Cardiopulmonary Bypass in a Case of Constrictive Pericarditis Following Coronary Artery Bypass Grafting|
|The operation for constrictive pericarditis after coronary artery bypass grafting (CABG) needs complete pericardiectomy without injury to the bypass graft. A 60-year-old man had pleural effusion a month after CABG. Right atrial pressure (RAP), right ventricular pressure (RVP), and pulmonary capillary wedge pressure (PCWP) were elevated and RVP showed a dip and plateau sign on cardiac catheterization. We diagnosed heart failure due to constrictive pericarditis following CABG. Pericardiectomy was performed using a cardiopulmonary bypass through a median sternotomy. The Harmonic Scalpel was useful for dissecting the pericardium. After the operation, it took a month for the patient to improve. RAP, RVP and PCWP were decreasing, and the dip and plateau sign of RVP was improved. The pleural effusion disappeared and the patient was discharged on the 73rd postoperative day.
Jpn. J. Cardiovasc. Surg. 34: 44-47 (2005)
|Octreotide for Postoperative Chylothorax|
|Chylothorax is a serious complication that can jeopardize the outcome of thoracic surgery and prolong hospitalization. We report a 66-year-old man who underwent graft replacement for a distal arch aneurysm, in whom a persistent postoperative chylothorax developed. It was necessary to perform continuous drainage and conservative management. Administration of octreotide sharply decreased the drainage volume and the chylothorax disappeared within 2 weeks. Early administration of octreotide for postoperative chylothorax may shorten the therapeutic period.
Jpn. J. Cardiovasc. Surg. 34: 48-50 (2005)
|A Case of Open Stent Grafting for Thoracic Aortic Aneurysm Combined with Atypical Coarctation and Aortic Regurgitation|
|A 58-year-old woman admitted for further examination of the proximal descending thoracic aortic aneurysm (TAA) combined with atypical coarctation and aortic regurgitation (AR). The chest CT and aortography confirmed these diagnoses, and revealed a pressure gradient of 40mmHg at the descending thoracic aorta with a severe calcification of the aortic wall, and severe AR. We scheduled a one-stage operation for this patient. First, we performed aortic valve replacement. Then we made a graft replacement from the aortic arch to the descending aorta using a stent graft via the aortic arch. Finally we did a reconstruction for lower limb perfusion using an aorto-iliac (extra-anatomical) bypass. The patient is now doing well 3 years after the surgery without any endoleak and without any difference of blood pressure between upper and lower limbs.
Jpn. J. Cardiovasc. Surg. 34: 51-54 (2005)
|A Case of Abdominal Aortic Aneurysm Involved by Acute Type B Dissection Treated with One-Stage OPCAB and Y-Graft Replacement|
|An 83-year-old man had acute type B aortic dissection combined with a large athelosclerotic abdominal aortic aneurysm (AAA) over 8cm in diameter. The dissection advanced into the wall of the AAA. The patient was treated with strict medical therapy for two months and successfully underwent an early elective abdominal aortic repair concomitant with off-pump aorto-coronary bypass grafting. This strategy of meticulous medical management may improve clinical outcome for the acute phase in such rare cases.
Jpn. J. Cardiovasc. Surg. 34: 55-58 (2005)
|A Case of Superior Mesenteric Arterial Dissection Associated with Stanford Type B Acute Aortic Dissection|
|We report a case of superior mesenteric arterial revascularization by bypass grafting between the right external iliac artery and the superior mesentery artery for intestinal ischemia by the superior mesenteric arterial dissection associated with Stanford type B, DeBakey type IIIb acute aortic dissection. The patient was 48-year-old man with Marfan’s syndrome. He had received aortic root replacement with a composite graft 10 years ago. He suffered from sudden back pain and severe abdominal pain. Contrast enhanced computed tomography revealed the superior mesenteric arterial dissection accompanied by Stanford typeB acute aortic dissection. We performed bypass grafting using the greater saphenous vein between the right external iliac artery and the superior mesentery artery. A year later, we performed replacement of the descending thoracic aorta. The vein graft is patent, and he has been doing well since the operation.
Jpn. J. Cardiovasc. Surg. 34: 59-62 (2005)
|Excision of the Clavicle for the Treatment of Sternal Nonunion Following Open Heart Surgery|
|A 72-year-old woman had undergone a right upper lobectomy and thoracoplasty in 1954 and an aortic valve replacement in December 2001. She suffered from dysphagia in June 2002. X-ray film and CT-scan revealed a sternal partial nonunion. The treatment was resection of the clavicle, because of the adhesion behind the sternum and the sternal partial nonunion. The postoperative course was uneventful and she was discharged. However, she was transferred to our hospital because of hematoma and bleeding at the right clavicle 1 month after the operation. Emergency operation was performed because of injury of the ramus of artery subscapularis. We ligated the ruptured portion and additionally resected the clavicle. Her postoperative course was good. Resection of the clavicle is one choice for sternal partial nonunion after open heart surgery. However, when we resect the clavicle, we should consider preservation of the ligament, reconstruction of the ligament, and the clavicular excision range.
Jpn. J. Cardiovasc. Surg. 34: 63-66 (2005)
|Less Invasive Aortic Valve Replacement Following Coronary Artery Bypass Grafting Using the Internal Thoracic Artery: Usefulness of Balloon Occlusion of the Internal Thoracic Artery Graft|
|When performing aortic valve replacement (AVR) in patients with a past history of coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA), the patent ITA graft needs to be detached from the surrounding tissue and occluded to properly protect the myocardium. However, detaching the ITA graft from the surrounding tissue takes time, and caution must be exercised to avoid damaging the graft. Two patients with a past history of CABG using the ITA were scheduled to undergo AVR. To simplify AVR, a balloon was placed preoperatively, and was inflated during aortic occlusion to occlude the ITA graft. The myocardium was adequately protected in this manner. Furthermore, since adhesion detachment was limited to around the ascending aorta, operative duration was short and bleeding volume was low. Balloon occlusion of the ITA graft appears to be useful in reducing the invasiveness of AVR in patients with a past history of CABG.
Jpn. J. Cardiovasc. Surg. 34: 67-69 (2005)
|Prosthetic Valve Replacement in Corrected Transposition with Severe Tricuspid Valve Dysfunction|
|Tricuspid valve regurgitation, which is a main complication of corrected transposition of the great arteries (C-TGA), greatly influences prognosis like atrioventricular block, but there are many differing openions concerning the treatment of this condition childhood. In 2 cases of C-TGA (S.L.L.) without other cardiac anomalies, we performed tricuspid valve replacement for severe valve dysfunction.
Jpn. J. Cardiovasc. Surg. 34: 70-73 (2005)
|Two Cases of Mycobacterium fortuitum Infection after Open-Heart Surgery|
|Mycobacterial infection after open-heart
surgery is a rare complication. We report 2 cases of cutaneous
infection caused by Mycobacterium fortuitum (M. fortuitum).
Case 1: A 56-year-old man had wound infection from the 10th postoperative
day (POD). The growth of M. fortuitum was detected on
the 38th POD. Combination of multiple antibiotic therapy was
performed. He was cured after several recurrences of cutaneous
ulcer and abscess following 15 months. Case 2: A 26-year-old
man had wound infection from the 28th POD. Deep sternal infection
with mediastinitis developed. Bacteriological examination revealed
the growth of M. fortuitum on the 61st POD. Omentopexy
was performed on the 67th POD. Wound infection completely healed,
and the patient was discharged from our hospital on the 137th
POD. Mycobacterial infection should be considered when the wound
infection is resistant to ordina antibiotics.
Jpn. J. Cardiovasc. Surg. 34: 74-77 (2005)
|A Successful Operative Case of Delayed Repair for Acute Traumatic Aortic Rupture|
|Although recent progress in surgery for acute traumatic rupture of the thoracic aorta is encouraging, hospital mortality remains high due to associated fatal lesions. Delayed repair of acute aortic rupture, after management of critical lesions, has been reported in the literature with increasing frequency. We present here a successful operative case of a 54-year-old-woman with acute traumatic aortic rupture. She was admitted to the intensive care unit with loss of consciousness, rib fracture and lung contusion in order to investigate additional critical lesions under strict control of systolic blood pressure under 120mmHg. After completion of all diagnostic procedures, aortic repair was performed 2 days after the accident. The intima of the aorta was found to be disrupted for two thirds of the circumference and pseudoaneurysm was diagnosed. A gelatin-coated vascular prosthesis with one branch was interposed under cardiopulmonary bypass during which general heparinization, systemic hypothermia (20℃) and retrograde brain perfusion method were used. She recovered uneventfully and was discharged 2 weeks after the operation.
Jpn. J. Cardiovasc. Surg. 34: 78-82 (2005)