Japanese Journal of Cardiovascular Surgery Vol.34, No.6

Aortic Valve Replacement for Aortic Stenosis in Patients 70 Years and Older

(Department of Cardiovascular Surgery, Osaka City University Medical School, Osaka, Japan)

Yasuyuki Kato	Shigefumi Suehiro	Toshihiko Shibata
Yasuyuki Sasaki	Hidekazu Hirai	Shigeru Sakamoto
Kenu Fumimoto	Yasuyuki Bito	Manabu Motoki
Yosuke Takahashi

We studied 73 patients, 70 years of age or older, who underwent aortic valve replacement for aortic stenosis between October, 1990 and October, 2004. There were 31 men and 42 women with a mean age of 75.7±3.6 years. Mechanical valves were implanted in 37 patients, and bioprostheses in 36 patients. Operative mortality was 1 of 73 (1.4%) and the New York Heart Association functional class improved to class I or class II in all of the hospital survivors. Follow-up (100%) extended from 0.3 to 11.6 years（mean 3.7 years). There were 16 late deaths (5.9% per patient-year), including valve-related deaths in 6 patients. The overall survival rates at 5 and 10 years was 74.2% and 44.3%, respectively. The freedom from valve-related events at 5 and 10 years was 78.8% and 78.8%, respectively. The 10-year survival rates and freedom from valve-related events were not different between the patients with mechanical valves and those with bioprostheses. The size of the implanted valve did not influence the late survival or freedom from valve-related events. The outcome after aortic valve replacement in the elderly (70 years and older) was excellent with low operative mortality, and acceptable late mortality and morbidity. Thus, aortic valve replacement for elderly patients should have the same indications as for younger patients. Bioprostheses showed good long-term results with no structural valve deterioration, thromboembolism, or bleeding events. Mechanical valves, which required the maintenance of an anticoagulant therapy, were also useful with acceptable late morbidity. The long-term results with small valves (≦19mm) were comparable to the results with large valves (＞19mm) in the elderly. Thus, the use of these small valves in this particular age group seems to be acceptable.
　Jpn. J. Cardiovasc. Surg. 34: 389-394 (2005)

Comparison of Early and Midterm Result of Endovascular Aneurysm Repair and Open Repair in the Treatment of Abdominal Aortic Aneurysms

(Thoracic and Cardiovascular Surgery, Hepato-Biliary-Pancreatic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan)

Yoshifumi Iguro	Hiroyuki Yamamoto	Kenichi Arata
Akira Kobayashi	Masahiro Ueno	Kouji Tao
Syouichi Suehiro	Ryuzo Sakata

To evaluate a comparison for endovascular repair (EVAR) versus open repair (OR) for the treatment of abdominal aortic aneurysm (AAA). Data of all patients with infrarenal AAA treated electively, both with OR (107 cases) and EVAR (24cases), at our institute between January 1999 and March 2004 were retrospectively reviewed. No difference was found between the 2 groups for sex, age, and AAA size. Cases of chronic obstructive pulmonary disease (20.8% vs 6.5%, p＜0.04) and frequencies of laparotomy (25% vs 2.8%, p＜0.001) were significantly more in the EVAR group than the OR group. In the initial results, deployment of the stent grafts was successful in all cases and complete thrombosis of the aneurysm was achieved in 21 cases (87.5%). One graft occlusion and a wound infection occurred in the EVAR group. OR was successfully performed in all cases. These were 6 cases of paralytic ileus, 1 of re-operation for hemorrhage, 1 of respiratory failure, and 1 of ischemic colitis in the OR group. One hospital death occurred in each group. Mean blood transfusion (0ml vs 238±345ml) and operation time (131±53min vs 250±76min) were significantly less in the EVAR group than the OR group. In the long term results, the cumulative survival rate was 88.0±6.5% at 1 and 2 years, 80.6±9.2% at 3 years in the EVAR group; 99.0±0.9% at 1 year, 94.1±2.6% at 2 years, 87.7±3.9% at 3 years in the OR group, with no difference between the 2 groups regarding survival rate. Four new endoleak and 3 graft infections were encountered in the EVAR group. Freedom from stent graft-related complications was 81.3±8.5% at 1 year, 61.4±11.9% at 2 years, 47.8±12.6% at 3 years in the EVAR group, but 100% at 1, 2 and 3 years in the OR group. Freedom from procedure-related complications in the EVAR group was significantly lower than that in OR group. In the long term results, EVAR was associated with more procedure-related complications. This finding may justify reappraisal of currently accepted EVAR for AAA management strategies.
　Jpn. J. Cardiovasc. Surg. 34: 395-400 (2005)

Evaluation of Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis

(Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan)

Tsutomu Hattori	Hideaki Maeda	Hisaki Umezawa
Masakazu Goshima	Tetsuya Nakamura	Shinji Wakui
Tatsuhiko Nishii	Nanao Negishi

We report the efficacy of catheter-directed thrombolysis (CDT) for acute deep vein thrombosis. Between January 2003 and August 2004, 20 patients were treated with CDT for occlusive femoral, ilio-femoral and vena caval thrombosis, for less than 2 weeks from onset. Average age was 56.4 years (range 30-78 years), 11 patients were male, and the duration of leg symptoms was 4.4 days (range 1-12 days). Routine temporary inferior vena caval filters were used, and a multi-lumen catheter was inserted from the popliteal vein. Urokinase was used via the catheter by the combination drip infusion method and pulse-spray method. All patients received heparin and stasis of venous flow was prevented with intermittent pneumatic compression. If thrombus remained, mechanical thrombolysis was necessary. Metallic stents were implanted for iliac vein compression syndrome and organized thrombus. Venographic severity score (VS score) and extremity circumference were used to evaluate the effects of treatment. The duration of the treatment was 5.0±0.28 days (range 2-9 days) and the total dosage of urokinase was 1,025,000±57,000 units (range 360,000-1,680,000 unit). One (5%) iliac vein compression syndrome and two (10%) organized thrombi were treated by implanted metallic stents. Giant thrombi was captured by temporary inferior vena caval filters in two patients, but there was no pulmonary embolism. Two patients had thrombophilia, one was antiphospholipid syndrome and one was protein S deficiency. There was an early recurrence in one patient and re-CDT was needed. The VS score deteriorated to 6.2±2.5 (post CDT) significantly (p＜0.0001) from 26.2±6.3 (pre CDT). CDT for acute deep vein thrombosis was effective and its early outcome was acceptable.
　Jpn. J. Cardiovasc. Surg. 34: 401-405 (2005)

A Case of Endovascular Stent Graft Placement for a Proximal Anastomotic Aneurysm after Abdominal Aortic Aneurysm Surgery

(Division of Organ Regeneration Surgery, Faculty of Medicine, Tottori University, Yonago, Japan and Department of Cardiovascular Surgery, Hamada Medical Center*, Hamada, Japan)

Munehiro Saiki*	Hideki Nakashima	Tohru Hiroe
Yoshinobu Nakamura	Naruto Matsuda	Yasushi Kanaoka
Shingo Ishiguro	Shigetsugu Ohgi

　A 77-year-old man was hospitalized for a proximal anastomotic aneurysm 9 years after surgery for an abdominal aortic aneurysm. The aneurysm was located 3cm distal to the renal artery. The maximum diameter was 55mm. His medical history included a reoperation for the proximal anastomotic aneurysm and cerebral infarction. Endovascular stent grafting was performed because it was possible anatomically. Postoperatively, no endoleak nor migration were found. At present, the patient is being followed up regularly in the outpatient department. Endovascular stent graft placement can be an effective method for reoperation cases of an abdominal aortic aneurysm, and if it is possible anatomically, it should be attempted.
　Jpn. J. Cardiovasc. Surg. 34: 406-408 (2005)

Extended Retroperitoneal Approach for Ruptured Juxtarenal Abdominal Aortic Aneurysm in a Patient with a History of Laparotomy

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

Kimihiro Yoshimoto	Norihiko Shiiya	Takashi Kunihara
Keishu Yasuda

We reported a successful emergency operation for ruptured juxtarenal abdominal aortic aneurysm via an extended retroperitoneal approach. A 70-year-old man with a history of distal gastrectomy and pancreatoduodenectomy complained of epigastric pain and was transferred to our emergency room in a state of shock. Computed tomograpy demonstrated a ruptured juxtarenal abdominal aortic aneurysm and massive intraperitoneal hematoma. We performed emergency graft replacement through an extended retroperitoneal approach in order to control the aorta quickly, safely, and reliably. This approach is a useful option in the emergency treatment of ruptured juxtarenal abdominal aortic aneurysm.
　Jpn. J. Cardiovasc. Surg. 34: 409-412 (2005)

A Case of Infected Brachiocephalic Pseudoaneurysm with Fistulation to the Skin 11 Years after Radical Mastectomy and Irradiation for Right Breast Cancer

(First Department of Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan)

Yuichiro Yokoyama	Takeo Suzuki	Yoichi Yamashita
Hajime Maeta

A 57-year-old woman was admitted with intermittent bleeding and pus discharge from her right anterior chest. She had undergone radical mastectomy (Halsted operation) and irradiation for breast cancer 11 years previously. Skin ulcer with a bleeding fistula had appeared at the right clavicular region 6 months previously. An emergency operation was performed, since angiography revealed brachiocephalic pseudoaneurysm with fistulation to the skin. The brachiocephalic artery was exposed through a right cervical and middle sternal incision. The brachiocephalic artery was interposed with two segments of the great saphenous vein joined to make a proper graft in size. The infected area was filled by the greater omentum. A pedicle flap was used to close the large skin defect after removing the fistula. The postoperative course was uneventful and infection improved soon after the operation. The patient was discharged about one month after the operation. We reported a rare case of infected brachiocephalic pseudoaneurysm with fistulation to the skin after radical mastectomy and irradiation for breast cancer.
　Jpn. J. Cardiovasc. Surg. 34: 413-417 (2005)

A Case of Acute Aortic Dissection Following Coronary Artery Bypass Grafting, Complicated with Upper Extremity and Bowel Ischemia

(Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan)

Naru Chatani	Kazumasa Orihashi	Masaki Hamamoto
Katsuhiko Imai	Kenji Okada	Taijiro Sueda

A 65-year-old man had acute Stanford type A aortic dissection complicated with upper extremity paralysis, 7 months after coronary artery bypass grafting. The superior mesenteric artery (SMA) appeared patent on CT angiography. However, color Doppler ultrasonography revealed malperfusion of the SMA. Progressive metabolic acidosis indicated bowel ischemia. Although antihypertensive therapy was selected due to possible injury of the right internal thoracic artery (RITA) graft at thoracotomy, revascularization of the SMA and reconstruction of axillary arteries were indicated due to increased paralysis and acidosis. Following anastomosis of a saphenous vein graft between the iliac artery and the SMA, the color and movement of the small intestine apparently improved. The axillary artery was transected and reconstructed with fenestration. Metabolic acidosis improved after SMA bypass but before superior axillary artery reconstruction. Upper extremity paralysis improved. Seven days later, however, he complained of sudden onset of back pain associated with hypotension, which was due to cardiac tamponade. He underwent replacement of the ascending aorta, elevation of the aortic valve, and reimplantation of the radial artery graft. He had an uneventful postoperative course and was discharged with no remaining complaints. In this case, treatment of upper extremity and bowel ischemia was selected prior to central operation, and irreversible damage was avoided. Color Doppler ultrasonography was helpful for diagnosing bowel ischemia before progression to necrosis. It must be remembered that patency diagnosed with CT angiography does not necessarily rule out mesenteric ischemia.
　Jpn. J. Cardiovasc. Surg. 34: 418-421 (2005)

In Situ Reconstruction with a Rifampicin-Bonded Gelatin-Sealed Dacron Graft for Pseudoaneurysm after Root Replacement

(Department of Cardiovascular Surgery, Nagoya-Daini Red-Cross Hospital, Nagoya, Japan)

Wataru Kato	Kazuyoshi Tajima	Sachie Terasawa
Keisuke Tanaka	Jinnichi Iwase	Akinori Io

A 58-year-old man underwent aortic root replacement for annuloaortic ectasia (AAE) and aortic regurgitation (AR). The patient was readmitted because of chest discomfort 3 months after the first operation. Computed tomography showed a pseudoaneurysm of the ascending aorta. Re-aortic root replacement was done on an emergency basis. However, 16 days after the second operation, a pseudoaneurysm was revealed by computed tomography. The third operation was successfully performed using a rifampicin-bonded gelatin-sealed Dacron graft (GELSEAL^®; Sulzer Vascutek, Glasgow, UK). The postoperative course was uneventful.
　Jpn. J. Cardiovasc. Surg. 34: 422-424 (2005)

A Case of Abdominal Aortic Aneurysm with Ectopic Renal Artery

(Department of Cardiovascular Surgery, Toyama Prefectual Central Hospital, Toyama, Japan and Department of Vascular Surgery, Kamiichi General Hospital*, Toyama, Japan)

Hiroaki Yusa	Masahiro Toshima*	Takeshi Konuma
Shuichi Hoshino	Yasushi Nishiya

A 72-year-old man presented with abdominal aortic aneurysm (AAA) and was referred to our hospital by his physician. A computed tomography revealed a 95-mm AAA with three right renal arteries. The main right renal artery branched from the AAA, and two remaining arteries branched from the same level as the left renal artery. The patient underwent AAA repair and main right renal artery reconstruction without any renal protection. After the operation, renal function did not deteriorate. 3D-CT was useful for diagnosing renal artery branching, evaluation of renal blood perfusion, and determining the operation method.
　Jpn. J. Cardiovasc. Surg. 34: 425-428 (2005)

A Case of Aortic Valve Replacement Complicated by Autoimmune Hemolytic Anemia

(Department of Cardiovascular Surgery, Shizuoka City Hospital, Shizuoka, Japan)

Hidetoshi Masumoto	Mitsuomi Shimamoto	Fumio Yamazaki
Shoji Fujita	Masanao Nakai	Masatsugu Hamaji

A 72-year-old woman, who had been treated for autoimmune hemolytic anemia with prednisolone and azathioprine since 2002, was found to have mild aortic stenosis in 1994. In December 2003, she suffered congestive heart failure, and was on temporary mechanical ventilation. In February 2004, the maximum pressure gradient between left ventricle and aorta increased to 115.8mmHg on echocardiographic examination. On April 6, aortic valve replacement was carried out with a 19mm bioprosthesis (Carpentier-Edwards PERIMOUNT^®, Edwards Lifesciences, Irvine, California). Preoperative prednisolone administration was continued until the day of the operation. Four packs of washed red blood cells were transfused intraoperatively and four packs of red blood cells were transfused postoperatively. Before transfusion, haptoglobin and water-soluble prednisolone were administrated to prevent hemolysis. Oral prednisolone and azathioprine were reestablished on the third postoperative day. Her postoperative course was uneventful and she did not suffer either infection or hemolysis. She was discharged on the 30th postoperative day.
　Jpn. J. Cardiovasc. Surg. 34: 429-431 (2005)

Surgical Treatment of Cardiac Penetration Induced by Pericardiocentesis

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

Yasuhiro Sawada	Hitoshi Kusagawa	Koji Onoda
Takatsugu Shimono	Hideto Shimpo

We report a case of surgical treatment of iatrogenic cardiac trauma. A patient with cardiac tamponade was treated by pericardiocentesis. During pericardiocentesis both right and left ventricles were perforated. These perforations were repaired in the beating heart state using 2-0 monofilament mattress sutures reinforced by felt pledgets. Iatrogenic cardiac trauma is rare. Fatal complications might arise when proper procedures are not followed during the placement of a catheter for pericardiocentesis. Here we present successfull surgical treatment of cardiac penetrations induced by pericardiocentesis.
　Jpn. J. Cardiovasc. Surg. 34: 432-434 (2005)

A Case of Ischemic Cardiomyopathy and Left Bundle-Branch Block Surgically Treated with Coronary Artery Bypass Grafting, Therapeutic Angiogenesis and Biventricular Pacing

(Division of Organ Regeneration Surgery, Tottori University Hospital, Yonago, Japan)

Naruto Matsuda	Hideki Nakashima	Akira Marumoto
Yoshinobu Nakamura	Satoshi Kamihira	Yasushi Kanaoka
Shingo Ishiguro	Shigetsugu Ohgi

A 67-year-old man was referred to our department for surgical treatment of ischemic cardiomyopathy. Chest X-ray showed cardiomegaly with a cardiothoracic ratio of 62% and pulmonary congestion. CAG revealed multiple obstructive lesions in the left coronary artery system. LVG and UCG showed ventricular dilatation and dysfunction. ECG showed complete left bundle branch block with a QRS duration of 180ms. He underwent autologous bone marrow cell implantation and biventricular pacing concomitant with coronary artery bypass grafting. He is doing well after 15 months without any complications. Combination with therapeutic angiogenesis and cardiac resynchronization therapy may contribute to the development of new regenerative strategy for patients with severe ischemic cardiomyopathy.
　Jpn. J. Cardiovasc. Surg. 34: 435-439 (2005)

Late Renal Cell Carcinoma Metastasis to the Right Ventricle without Caval Involvement

(Department of Cardiovascular Surgery, Saitama Municipal Hospital, Saitama, Japan)

Satoru Suzuki	Kenichi Hashizume	Yoshiyuki Haga

A 72-year-old woman was admitted to our hospital because of a mass in the right ventricle. She has a history of renal cell carcinoma of the left kidney, which was completely removed by nephrectomy in 1996. Echocardiography, CT and MRI showed a large tumor in the right ventricle without any inferior vena cava involvement. A biopsy performed on that tumor confirmed that the tumor was a metastatic tumor in the right ventricle from the renal cell carcinoma. The tumor grew quickly, and almost completely obstructed the right ventricular outflow tract. On February 24, 2004; an operation was performed to remove the tumor, which protruded from the ventricular septum and occupied the right ventricular cavity from the attachment of the tricuspid valve to the right ventricular outflow tract close to the pulmonary valve. A transannular patch was placed in order to dilate the right ventricular outflow tract. Histopathology diagnosed that the tumor was a metastasis from the renal cell carcinoma. The postoperative course was uneventful. Interleukin-2 was administered postoperatively. Echocardiography performed eight months after the surgery showed that although the tumor in the right ventricle had grown, it had not produced stenosis of the right ventricular outflow tract. The patient died as a result of the recurrent tumor blocking the right ventricular outflow tract 11.5 months after the surgery.
　Jpn. J. Cardiovasc. Surg. 34: 440-444（2005）

A Living Related Donor Liver Transplant Recipient Who Needed an Aortic Valve Replacement and Redo CABG after Ross Operation

(Department of Cardiovascular Surgery, Memorial Heart Center, Iwate Medical University, Morioka, Japan)

Tsuyoshi Kataoka	Hiroshi Izumoto	Junichi Koizumi
Kazuaki Ishihara	Kohei Kawazoe

We report a successful open heart reoperation of a 14-year-old girl with Alagille syndrome. The patient underwent a living related donor liver transplantation at the age of 9 years in another hospital because of liver failure due to a paucity of interlobular bile ducts. Two years later, because of progression of her aortic valve stenosis, Ross operation and CABG were performed in the same hospital. Afterwards, her neoaortic valve regurgitation developed due to aortic root dilatation and myocardial ischemia developed by anastomosis site stenosis. She started to experience frequent angina attacks. She underwent AVR and redo CABG in our institution in April 2002. Her pre- and postoperative liver function was normal and no special procedure for the liver was needed, and she was discharged on the 18th postoperative day with no complications. In this country, few open heart surgeries for liver transplant recipient have been performed, and no case of reoperation has yet been reported. If pre- and postoperative liver function are normal, pre- and postoperative management of open heart surgery for a transplant may be perfomed conventionally.
　Jpn. J. Cardiovasc. Surg. 34: 445-448 (2005)