Japanese Journal of Cardiovascular Surgery Vol.34, No.3

Mitral Reoperation via Partial Sternotomy

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

Nobuaki Kaki	Takao Imazeki	Yoshihito Irie
Hiroshi Kiyama	Noriyuki Murai	Hirotugu Yoshida
Shigeyoshi Gon	Souichi Shioguchi	Masahito Saito
Shuichi Okada

A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: n＝8, group F: n＝1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F: 87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2,405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%)，2/13(15%) respectively. Hospital mortality was 0/20 (0%)，2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.
　Jpn. J. Cardiovasc. Surg. 34: 163-166 (2005)

Long Term Effects of 19mm Bileaflet Aortic Valve Prosthesis

(Department of Cardiovascular Surgery, Jichi Medical School, Omiya Medical Center, Saitama, Japan) Satoshi Ito Koji Kawahito Masashi Tanaka Kenichiro Noguchi Atushi Yamaguchi Seiichiro Murata Koichi Adachi Hideo Adachi Takashi Ino

We reviewed our experience with 19mm size aortic valve prostheses for cases with small aortic annulus. Forty-six patients operated on between 1990 and Septembr 2002 were enrolled in this study. Clinical late assessment was performed to evaluate the incidence of valve-related complications, residual transprosthetic gradient, left ventricular mass index (LVMI), and NYHA functional class. Postoperative echocardiography was performed to evaluate hemodynamic performance of the prostheses. Follow up was 1 to 12.7years (mean 5.3±3.6). There was no hospital mortality (0%). Actuarial survival rates at 10years were 81.4±1.5%. The late postoperative peak gradient was 25±11mmHg. LVMI was significantly reduced in late phase. NYHA functional class significantly improved in the late period. Although 19mm size aortic valve prosthesis remains small transprosthetic pressure gradient, LVMI significantly reduced and patient activity was satisfactory maintained in the late period. 　Jpn. J. Cardiovasc. Surg. 34: 167-171 (2005)

Midterm Results of Mitral Valve Repair with a Rigid Ring

(Department of Cardiovascular Surgery, Kochi Municipal Hospital, Kochi, Japan) Fuyuhiko Yasuda Mitsuteru Handa Atsushi Takamori Tomoaki Suzuki Yoichirou Miyake Yuuo Kanamori Manabu Okabe

The purpose of this study was to analyze our results of mitral valve repair with a rigid annuloplasty ring (Carpentier-Edwards ring; Baxer-Edwards CVS Laboratories; Lrvine, Calif) in terms of its efficacy and safety. We have examined postoperative mitral regurgitation (MR) and left ventricular diastolic dimension (LVDd) in 63 cases of mitral valvoplasty during a period of 5 years. The operative methods were 20 cases of tendon reconstruction, 42 cases of quadrangular resection, and 15 cases of annuloplasty alone. Operative mortality and freedom from complications were examined at the mean 41.2 months after the operation. There were no operative deaths, and no case with severe MR postoperatively. From echocardiographic findings, the grade of MR changed from 3.13 to 0.28 postoperatively, and LVDd changed from 58.4±6.71 to 48.7±6.3ml postoperatively. Reoperation was performed in 2 cases (3.2%) several years after the first operation. The rate of midterm mortality was 4.8%. The postoperative mitral valve area was 2.85cm2 in size of 26mm ring, 2.95cm2 in size of 28mm, 3.09cm2 in size of 30mm, which were measured from PHT (pressure half time) of the Doppler echocardiography. In conclusion, mitral valve repair with rigid annuloplasty ring (CE ring) provided good results for MR at midterm follow-up. 　Jpn. J. Cardiovasc. Surg. 34: 172-175 (2005)

Coronary Artery Bypass Grafting Using in Situ Bilateral Internal Thoracic Arteries

(Department of Cardiovascular Surgery, Kochi Municipal Hospital Kochi, Japan) Tomoaki Suzuki Manabu Okabe Fuyuhiko Yasuda Yoichiro Miyake Satofumi Tanaka

Coronary artery bypass grafting (CABG) using in situ skeletonized arterial conduits with an off-pump technique is a high quality and minimally invasive procedure. The internal thoracic artery (ITA) is the most reliable conduit as grafting the left anterior descending artery and circumflex arteries with bilateral ITAs leads to better long-term patient outcomes. In this study, we demonstrated the feasibility and usefulness of off-pump coronary artery bypass grafting surgery using bilateral ITAs. A total of 217 consecutive CABG cases using skeletonized ITA grafts were studied and they were divided into 2 groups are using unilateral ITA (UITA, n＝104) and the other using bilateral ITA (BITA, n＝113). OPCAB was completed in 94% (98/104) in the UITA group and in 99% (112/113) in the BITA group. The mean number of distal anastomoses per patient was 3.02 in the UITA group and 3.63 in the BITA group. The ITAs were used in situ in 100% (104 ITAs) in the UITA group and in 96% (217 ITAs) in the BITA group. One patient in the UITA group suffered from mediastinitis and one patient in the BITA group died due to intestinal ischemia 3 days after operation. Postoperative angiography was performed before discharge in 101 patients in UITA and 99 in BITA. The patency rate was 98.7% in the UITA group and 99.4% in the BITA group. OPCAB with bilateral skeltonized ITAs is a feasible and safe technique with excellent early clinical results and graft patency. OPCAB using in situ skeletonized artery conduits can become a standard surgical treatment for ischemic heart disease. 　Jpn. J. Cardiovasc. Surg. 34: 176-179 (2005)

Mid-Term Results of Entry Closure for Chronic Type B Dissecting Aortic Aneurysm

(Second Department of Surgery, Miyazaki Medical College, Miyazaki, Japan)

Kouji Furukawa	Kunihide Nakamura	Mitsuhiro Yano
Yoshikazu Yano	Masakazu Matsuyama	Kazushi Kojima
Yusuke Enomoto	Toshio Onitsuka

We performed entry closure for the chronic type B dissecting aneurysms by open surgical procedure or endovascular stent-graft placement. The purpose of this study is to evaluate the mid-term results of these patients with respect to mortality, morbidity, change of aneurysm diameter and outcome of the false lumen. From 1996 to 2003, entry closure was performed on 8 patients with chronic dissecting aortic aneurysm with an entry site in the descending aorta and visceral arteries that originated from the true lumen. The study population consisted of 4 men and 4 women with a mean age of 63.8±10.9 years. One patient had a DeBakey type III a and 7 patients had a DeBakey type III b dissecting aneurysm. Five patients underwent surgical entry closure and 3 patients underwent endovascular stent-graft placement. The mean follow-up period was 40±29 months. No operative mortalities, complications of paraplegia or visceral ischemia occurred. A leak was identified in 3 patients, 1 patient underwent an open repair with descending aortic replacement and 1 patient required additional stent-grafting. In the follow-up period, 1 patient died of cancer, but there were no dissection-related mortalities or re-operations for increase in size. With the exception of 1 case with a graft replacement, complete thrombosis of the thoracic aortic false lumen was achieved in 6 cases. There were no significant differences in the pre- and postoperative aortic diameter. Overall, complete thrombosis of the thoracic aortic false lumen was achieved with a high rate of success without a dissection-related mortality. Long-term follow-up, however, is necessary because a reduction in size did not occur in some cases.
　Jpn. J. Cardiovasc. Surg. 34：180-184 (2005)

Comparison of Clinical Outcomes Using EuroSCORE for Coronary Artery Bypass Grafting with or without Cardiopulmonary Bypass

(Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan)

Keiichi Hirose	Senri Miwa	Takeshi Nishina
Tadashi Ikeda	Masashi Komeda

We reviewed 223 cases of isolated coronary artery bypass grafting (CABG) during the past 6 years, and used the EuroSCORE to assess the differences in clinical outcomes between off-pump CABG (OPCAB) and on-pump CABG (conventional CABG: CCABG). After March 2000, our first choice has been OPCAB, with CCABG selected only for cases with unstable hemodynamics. The total of 223 isolated CABG cases consisted of 129 OPCAB and 94 CCABG, but after March 2000, 94 OPCAB and 42 CCABG were performed. Mean EusoSCORE was 5.8 for OPCAB and 4.1 for CCABG, and corresponding expected survival rates were 7.20% and 5.04%. The 3 cases of hospital death (mortality, 1.3%) all belonged to the earlier CCABG groups and were not related to cardiac death. After March 2000, no hospital deaths occurred in either group. Midterm results showed 5 deaths, but these were not related to cardiac death, either. There were no significant differences between the 2 groups in terms of hospital complications other than long mechanical ventilation time, which was markedly longer only for the OPCAB groups (p＜0.01). Mean number of grafts was significantly high for patients in the CCABG groups (OPCAB 2.1 vs. CCABG 2.8; p＜0.05). We have therefore been using OPCAB for high-risk cases, and midterm results of our CABG patients were satisfactory.
　Jpn. J. Cardiovasc. Surg. 34: 185-189 (2005)

Four Cases of Delayed Hypersensitivity Reaction to Vancomycinafter Cardiac Surgery

(The Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Japan) Hitoshi Suzuki Shinji Kanemitsu Toshiya Tokui Yuo Kanamori Yoshihiko Kinoshita

We report 4 cases of delayed hypersensitivity reaction to Vancomycin (VCM) after cardiac surgery. Case 1: A patient developed sepsis and mediastinitis after aortic valve replacement (AVR) for aortic valve insufficiency. Case 2: A patient developed mediastinitis after coronary artery bypass grafting (CABG) for effort angina pectoris. Case 3: A patient developed pneumonia after AVR for aortic valve infective endocarditis. Case 4: A patient developed sepsis after CABG for acute myocardial infarction. All of them received VCM intravenously and their infections improved. However, sudden high fever, skin rush and eosinophilia occurred 12 or 13 days after the initiation of therapy. These symptoms resolved after halting VCM administration. We need to take examine eosinophils when considering further administration of VCM. 　Jpn. J. Cardiovasc. Surg. 34：190-193 (2005)

Aortic Root Replacement with a Freestyle Porcine Valve in a Young Woman with Systemic Lupus Erythematosus and Antiphospholipid Antibodies

(Department of Cardiovascular Surgery, Kawachi General Hospital, Higashiosaka, Japan) Harumasa Yasuda Nobuo Sakagoshi

Aortic root replacement with a Freestyle™ stentless porcine valve (Medtronic Inc.) was performed on a 32-year-old woman for aortic root aneurysm. The patient had been given a diagnosis of systemic lupus erythematosus and had been maintained on steroid therapy for 15 years. Lupus anticoagulant was present and the anticardiolipin antibody titer was abnormal as follows: IgG, 2.0IU/ml (normal＜1.0IU/ml). For the patient requiring aortic root reconstruction, many options are available. The use of a biological valved conduit should be considered for patients in whom anticoagulation is not desirable. The Freestyle™ stentless porcine valve offers an acceptable alternative to mechanical prostheses, especially for cases with contraindication for anticoagulant therapy, associated with antiphospholipid antibodies. 　Jpn. J. Cardiovasc. Surg. 34: 194-197 (2005)

Malignant Hyperthermia after Surgical Repair of Acute Type A Aortic Dissection

(Department of Cardiovascular Surgery, Himeji Cardiovascular Center, Himeji, Japan) Tomoki Hanada Nobuhiko Mukohara Naoto Morimoto Hironori Matsuhisa Ayako Maruo Hiroya Minami Keitaro Nakagiri Masato Yoshida Hidefumi Obo Tsutomu Shida

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO2 , low level of PaO2 and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7℃. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12,446 IU/l and serum myoglobin elevated to a very high level (36,500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated. 　Jpn. J. Cardiovasc. Surg. 34: 198-201 (2005)

Cardiac Operations in Two Patients Aged 90 or Over

(Department of Cardiovascular Surgery, Okinawa Prefectural Naha Hospital, Naha, Japan) Tadao Kugai Hiroshi Munakata Nobuhiro Nagata

Cardiac surgery in patients aged 90 years or older is not common. We report 2 successful cases in nonagenarians. A 90-year-old man underwent the Bentall operation for aortic root aneurysm with moderate aortic valve regurgitation. A 91-year-old man underwent aortic valve replacement and single CABG (LITA to LCX) for severe aortic valve stenosis with single coronary artery disease. Their postoperative courses were uneventful. We emphasize that cardiac surgery in nonagenarians should not be withheld on the basis of age alone, but should be based on careful assessments of the relative medical risks and benefits, as well as the wishes of the patient and family. 　Jpn. J. Cardiovasc. Surg. 34: 202-204 (2005)

Successful Surgical Treatment for Fungal Endocarditis of the Ascending Aorta after Aortic Valve Replacement

(Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Japan) Seiji Kinugasa Fumitaka Isobe Keiji Iwata Yukiya Nomura Motoko Saito Masatoshi Hata

A 69-year-old woman underwent aortic valve replacement (AVR) for prosthetic valve (Freestyle™ stentless valve) endocarditis (PVE) in April 2001. The patient was admitted to our hospital with diarrhea and tarry stools in January 2002 and was treated with intravenous hyperalimentation. She had fever and inflammatory findings at 1 week after admission, and was given intravenous antibiotics. Symptoms and laboratory findings improved gradually, but transesophageal echocardiography revealed a mobile mass in the ascending aorta near the noncoronary sinus of Valsalva. The serum β-D glucan level was elevated and blood culture was positive for Candida parapsilosis. These findings suggested fungal endocarditis of the ascending aorta, so the patient underwent surgery. Vegetation was attached to the aortic wall near the noncoronary sinus of Valsalva. It was removed with part of the ascending aorta, followed by reconstruction with a gusset xenograft. In addition, aortic valve replacement was performed with a mechanical valve. The resected tissue grew C. parapsilosis, so parenteral anti-fungal drugs were administered intravenously for 8 weeks after surgery. Although cerebral infarction occurred, she was discharged on the 133rd postoperative day. There was no recurrence of infection and she remained on oral anti-fungal medication for 24 months postoperatively. 　Jpn. J. Cardiovasc. Surg. 34: 205-208 (2005)

A Case of Leaflet Folding Plasty for Mitral Regurgitation due to Bilateral Commissural Prolapse

(Department of Cardiovascular Surgery, Yamanashi Central Hospital, Kofu, Japan) Hiroshi Amano Koji Tsuchiya Masato Nakajima Kensuke Kobayashi Koki Takizawa

We report a 77-year-old woman who underwent mitral valve repair using leaflet folding plasty for mitral regurgitation due to bilatelal commissural prolapse. A Carpentier prosthetic ring was applied to remodel the annulus and to reinforce repair. Postoperative echocardiography revealed no regurgitation and good mitral valve opening. Leaflet folding plasty is considered to be a simple and effective technique to accomplish mitral valve repair for mitral regurgitation due to commissural prolapse. 　Jpn. J. Cardiovasc. Surg. 34: 209-211 (2005)

A Case of Reoperation for Mitral and Tricuspid Regurgitations with Severely Calcified Aorta by Hypothermic Ventricular Fibrillation

(Department of Cardiovascular Surgery, Machida Civil Hospital, Machida, Japan and Department of Cardiovascular Surgery, Saitama Prefectural Circulatory and Respiratory Center*, Saitama, Japan) Shingo Taguchi Yoshimasa Sakamoto Hiromitsu Takakura*

A 71-year-old man who had mitral and tricuspid regurgitations with severely calcified aorta had been called off an elective operation 4 years ago, because cardiopulmonary bypass (CPB) could not be established intraoperatively operation. This time, mitral valve replacement and tricuspid annuloplasty was performed by left axillary arterial cannulation and moderate hypothermic ventricular fibrillation after resternotomy. Calcification of the aorta is sometimes more severe than detected by preoperative CT scan, as in the present case. Therefore, it is necessary and recommended for cases of calcified ascending aorta to be fully examined and, based on the results decided alternative modalities. 　Jpn. J. Cardiovasc. Surg. 34: 212-215 (2005)

Hemodiafiltration during Off-Pump Coronary Artery Bypass Grafting for a Chronic Dialysis Patient

(Department of Cardiovascular and Thoracic Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan) Atsushi Fukumoto Hitoshi Yaku Kiyoshi Doi Satoshi Numata Kyoko Hayashida Mitsugu Ogawa Tomoya Inoue Nobuo Kitamura

Patients on chronic hemodialysis, undergoing coronary artery bypass grafting (CABG) have high perioperative mortality and morbidity. In order to reduce the perioperative risks, we performed intraoperative hemodiafiltration (HDF) during off-pump CABG (OPCAB). A 62 year-old-man, who had been on dialysis for 2 years, was admitted with a sensation of chest compression. A coronary angiography revealed 75% stenosis with severe calcification in the left anterior descending artery and 90% stenosis in the second diagonal branch. During the operation, veno-venous HDF was started, using a double lumen catheter that was introduced into the femoral vein at the same time that a skin incision was made. During the exposure of the diagonal branch by rotating the heart, the blood flow of HDF was decreased and dehydration was halted to avoid hemodynamic deterioration. The patient was extubated 1.5 h after the operation and did not require continuous hemodiafiltration (CHDF) in the intensive care unit (ICU). Routine hemodialysis was restarted on the 3rd postoperative day. The postoperative course was uneventful, and the patient was discharged to home on the 11th postoperative day. HDF during OPCAB for this chronic dialysis patient was observed to be effective and yielded an excellent postoperative recovery without CHDF in the ICU. 　Jpn. J. Cardiovasc. Surg. 34: 216-219 (2005)

Simultaneous Cardiac Resynchronization Therapy and Cardiac Surgery in a Patient with Triple Coronary Vessel Disease, Mitral and Tricuspid Valve Insufficiency after Three-Area Old Myocardial Infarction

(Department of Cardiovascular Surgery, Ayase Heart Hospital, Tokyo, Japan)

Takashi Miura	Imun Tei	Takashi Oshitomi
Kazuki Sato	Eiichi Tei

We performed cardiac resynchronization therapy (CRT) in addition to coronary artery bypass grafting (CABG), mitral valve replacement (MVR) and tricuspid valve annuloplasty (TAP) in a 72-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 38%), triple coronary vessel disease, and mitral and tricuspid valve insufficiency after three-area old myocardial infarction. Electrocardiography showed no change in the QRS interval after CRT. However, tissue Doppler echocardiography showed synchronicity of the septum and posterior segments in the left ventricle, and that contraction of the septum was in the systolic phase of the cardiac cycle after CRT. New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in which ischemia and volume overload were improved by CABG, MVR and TAP may improve regional cardiac function and synchronicity.
　Jpn. J. Cardiovasc. Surg. 34: 220-224 (2005)

Vacuum-Assisted Closure with a Portable System in the Treatment of Sternum Dehiscence after Cardiac Surgery

(Department of Cardiovascular Surgery, Ibaraki Seinan Medical Center Hospital, Ibaraki, Japan)

Kanji Matsuzaki

Hideya Unno

A 62-year-old man with ischemic heart disease suffered from a poststernotomy wound trouble after coronary artery bypass grafting. We performed vacuum-assisted closure (VAC), minimally invasive treatment for difficult wounds, because he had severe heart failure and depressive disorder. This therapy assists in wound healing by applying localized negative pressure to the surface of the wound, and its effectiveness for poststernotomy mediastinitis has already been reported in several countries. It is, however, very difficult for us to obtain a manufactured device, the V.A.C.^® system (KCI, San Antonio, Texas), which is not available in Japan yet. Therefore, we had to make a self-made system which combined RetractorPad^® polyvinyl alcohol hydrofoam (Mondomed NV, Harmont, Belgium) and J-VAC^® closed wound drainage system (Johnson&Johnson, Tokyo, Japan). This self-made system, without a vacuum pump machine, was small and light enough to be carried by the patient even in the early postoperative period. In this case, VAC resulted in complete healing of the wound in about 3 weeks with little pain, stress, effort and time, and with reasonable cost in comparison to conventional treatment. This is a useful and hopeful option in the treatment of not only sternum dehiscence but also mediastinitis after cardiac surgery, especially for high-risk patients.
　Jpn. J. Cardiovasc. Surg. 34: 225-228 (2005)

Successful Revascularization in a Case of Subclavian Steal Syndrome

(Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan) Masamichi Ozawa Naomichi Uchida Hidenori Shibamura

We successfully treated a case of extra-anatomical revascularization using an extrathoracic approach for what is called subclavian steal syndrome, and we describe the operative method. A 65-year-old man with dizziness was examined by digital subtraction assessment and given a diagnosis of subclavian steal syndrome by occlusion of left subclavian artery. He was relatively young for his age with good general condition, and no lesion were detected in aortic arch branches and cerebral arteries except for left subclavian artery. Therefore we performed left common carotid artery-subclavian artery bypass using a prosthetic graft. The preoperative symptoms and difference in blood pressure among arteries of the upper limbs disappeared, and he was discharged 15 days after surgery. 　Jpn. J. Cardiovasc. Surg. 34: 229-232 (2005)

Multiple Mycotic Aneurysms of the Thoracoabdominal Aorta and Abdominal Aorta

(Department of Cardiovascular Surgery, Mie University School of Medicine, Tsu, Japan) Iwao Hioki Yasuhiro Sawada Koji Onoda Takatsugu Shimono Hideto Shimpo Isao Yada

A 59-year-old man had been treated at another institution for bacterial meningitis (Streptococcus pneumoniae). He had severe back pain and lumbago. Computed tomographic (CT) scanning of the chest and abdomen demonstrated saccular aneurysms at the diaphragm in the descending thoracic aorta and the infrarenal abdominal aorta. An extended left posterolateral retroperitoneal incision was performed for resection of the thoracoabdominal aneurysm and replacement of an in situ dacron graft with rifampicin using cardiopulmonary bypass. The abdominal aneurysm was resected and replaced by an in situ dacron graft with rifampicin. The grafts were covered with a pedicled omental flap. The tissue culture was negative. After subsequent intravenous antibiotic therapy for 2 months, the patient was discharged without any evidence of remaining infection. 　Jpn. J. Cardiovasc. Surg. 34: 233-236 (2005)