Japanese Journal of Cardiovascular Surgery Vol.35, No.2

Aortic Valve Replacement in Patients Aged 80 or Older

(Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Japan)

Masato Yoshida	Nobuhiko Mukohara	Hidefumi Obo
Nobuchika Ozaki	Tasuku Honda	Kenichi Kim
Kazuhiro Mizoguchi	Takeshi Inoue	Keigo Fukase
Takuya Misato	Tsutomu Shida

With the progressive aging of the Japanese population, cardiac surgeons are increasingly faced with elderly patients. We have studied 29 consecutive patients, 80 years of age or older, who underwent aortic valve replacement at our institution between January 2000 and December 2003. Mortality, morbidity and late follow-up results were compared to those in 36 patients aged from 64 to 75 years old undergoing the same procedure over the same time period. The older patient group had a significantly higher incidence of calcified aortic stenosis and emergency operations and a higher score of NYHA functional class. Hospital mortality was 2 of 29 (6.9%) in the older patient group and 2 of 36 (5.6%) in the control group (ns). Postoperative renal failure and respiratory failure which needed prolonged ventilator support occured significantly more often in the older patient group. However, there was no significant difference between the 2 groups in terms of hospital stay. Almost all octogenarians showed improved NYHA functional class to class I or II after the operations. The actuarial survival rate was 89% in the older patient group and 78% in the control group at 3 years. The late survival rate and cardiac event-free rate were not significantly different between these 2 groups. Following aortic valve replacement, octogenarians, despite more compromised pre-operative status had good relief of symptoms, a favorable quality of life and a similar late survival to the younger patient groups. These findings support the recommendation that valve replacement should be performed in octogenarians with symptomatic aortic valvular disease.
　Jpn. J. Cardiovasc. Surg. 35: 61-65 (2006)

Effect of Diabetes Mellitus on Early and Mid-Term Results after Off-Pump CABG

(Department of Cardiovascular Surgery, Kanto Medical Center NTT EC, Tokyo, Japan)

Yoshitsugu Nakamura	Kiyoharu Nakano	Hayao Nakatani
Akihiko Gomi	Atsuhiko Sato	Koichi Sugimoto

It has been reported that diabetes mellitus is a significant risk factor for adverse outcomes after conventional CABG using cardiopulmonary bypass. However, the effects of diabetes on postoperative outcomes after off-pump coronary artery bypass grafting (OPCAB) are unclear. The effects of diabetes on early and mid-term results were studied by comparing the outcomes between 82 patients (65±5 years) with diabetes and 112 patients (68±11 years) without diabetes. The diabetic group included a greater preoperative presence of renal insufficiency (22.0% vs 8.9%, p＝0.011) and history of cerebral vascular accident (25.6% vs 11.6%, p＝0.012). Strategies, including graft choice, were not changed by presence of diabetes. The use of bilateral internal thoracic arteries (70.7% diabetes vs 67.0% nondiabetes), and frequency of total arterial bypass were similar in the 2 groups. The number of distal anastomoses was higher in the diabetic group (3.0±0.9 vs 2.7±0.9, p＝0.042). The operation time and frequency of blood transfusion were similar in both groups. There was no hospital death in either group. Although mechanical ventilation time and postoperative ICU stay did not differ, hospital stay was significantly longer in the diabetic group (16.2 vs 13.3 days, p＝0.0085). Postoperative major complications including atrial fibrillation were not significantly different between the 2 groups. Minor wound infection occurred in 2 patients, 1 in each group. There was no mediastinitis in either group. During the mean follow-up period of 20.8 months (1-39), there were two sudden deaths in the diabetic group, but no other cardiac death in either group. Cardiac event-free rate did not differ between the 2 groups. Although hospital stay in diabetic patients was longer than that in nondiabetic patients, early and mid-term results of OPCAB were not significantly affected by diabetes mellitus.
　Jpn. J. Cardiovasc. Surg. 35: 66-71 (2006)

A Case of Redo Mitral Valve Replacement (MVR) Complicated with Prosthetic Valvular Endocarditis (PVE) and Vertebral Osteomyelitis Post MVR

(Department of Thoracic Surgery, Ome Municipal General Hospital, Ome, Japan and Thoracic Cardiovascular Surgery Department, Tokyo Medical and Dental University*, Tokyo, Japan)

Naoto Miyagi	Nagahisa Oshima	Toshizumi Shirai
Makoto Sunamori*

A 74-year-old woman was given a diagnosis of mitral regurgitation (MR) and tricuspid regurgitaton (TR) underwent mitral valve replacement (MVR) and tricuspid annuloplasty (TAP). Pacemaker implantation was necessary because of postoperative atrial fibrillation (Af) followed by bradycardia on the postoperative day 14. Five months later, she was again admitted to our hospital because of fever. A blood culture revealed Streptococcus sangius. Symptoms improved with the administration of antibiotics. Twenty days after discharge, she suffered back pain and fever. A CT scan showed destructive changes in the thoracic vertebrae and echocardiography revealed mitral vegetations. A blood culture revealed Streptococcus agalactiae. Symptoms subsided with the administration of antibiotics. However, new mitral regurgitation was recognized so the patient underwent redo MVR. The patient's recovery was uncomplicated after surgery, and she was discharged on the 104th post-operative day.
　Jpn. J. Cardiovasc. Surg. 35: 72-75 (2006)

Results and Assessments of Saphenous Vein Grafts Flow with Left Axillary to Left Anterior Descending Coronary Artery Bypass

(Department of Cardiovascular Surgery, Makiminato Central Hospital, Urasoe, Japan)

Kunio Toge	Moriichi Sugama

Axillary artery-to-coronary artery bypass using a saphenous vein graft provides a simple and safe method of applying a minimally invasive coronary bypass grafting procedure when the internal thoracic artery is not an adequate conduit. Although this may allow use of a minimally invasive coronary bypass procedure, the patency of this technique is unknown. The purpose of this study was to review our experience in the clinical results and problems with left axillary artery to left anterior descending coronary artery bypass. Since 1999 we have applied this procedure in 5 patients (with a mean age of 72.6years). All patients were high-risk candidates because of cerebral infarction, depressed renal function, previous heart operation, or previous surgical treatment of esophageal carcinoma. The saphenous vein was anastomosed to the left axillary artery, where it entered the thorax and continued to the left anterior descending coronary artery. The mean operation time was 3.1h (range: 2.3 to 4.7h). Angiography or thallium studies or Doppler echocardiography were performed to confirm graft patency. Postoperative angiography showed all grafts to be patent. All patients were discharged. During a mean follow-up period of 10.4months, one patient in whom graft distributed over the subclavian vein died due to failure of the graft 6 months after the operation. Four patients were free from cardiac events. Axillary artery-to-coronary artery bypass using the saphenous vein is an effective and safe technique for high-risk patients if we pay attention to the course of the graft. In an effort to evaluate flow characteristics of the saphenous vein grafts (SVG) after the operation, we used transcutaneous ultrasound study with Doppler flow velocimetry of SVG. The diameter of the vessel, systolic peak velocity, diastolic peak velocity, and velocity ratio were recorded. Use of this may allow noninvasive identification of the bypassing grafts and comparison of their postoperative blood flow waveforms in patients following minimally invasive direct coronary artery bypass (MIDCAB). It can also be performed repeatedly to monitor the patient's clinical course after surgery.
　Jpn. J. Cardiovasc. Surg. 35: 76-80 (2006)

A Case of Coronary-Pulmonary Artery Fistula with a Giant Aneurysm

(Department of Cardiovascular Surgery, Iwate Prefectural Central Hospital, Morioka, Japan)

Koichi Nagaya	Susumu Nagamine	Kenji Osaka
Hidemitsu Kakihata

A 67-year-old woman was admitted to our hospital for examination of a chest X-ray abnormality. Chest computed tomography and coronary angiography revealed a giant aneurysm and coronary-pulmonary artery fistula originating from both the proximal left anterior descending and the right coronary artery. The fistula was ligated and the aneurysm was resected by means of extracorporeal circulation. The postoperative course was uneventful. Computed tomography and coronary angiography showed that the aneurysm and coronary-pulmonary artery fistula had completely disappeared.
　Jpn. J. Cardiovasc. Surg. 35: 81-84 (2006)

The Effective Use of Redo of Off-Pump Coronary Artery Bypass Grafting through a Left Thoracotomy with a Patent Left Internal Thoracic Artery Graft

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

Atsutomo Morishima	Nozomu Sasahashi	Kouji Ueyama

Redo of off-pump coronary artery bypass grafting (CABG) through a left thoracotomy with a patent left internal thoracic artery graft was very effective. A 62-year-old man was admitted because of unstable angina for whom CABG had been performed 6 years earlier (LITA-LAD, Ao-SVG-OM1), the saphenous vein graft soon become occluded. Coronary angiography revealed total occlusion of the right coronary artery (RCA) ＃1. For vasoconstruction of the left circumflex artery (LCx) and RCA, off-pump coronary artery bypass (OPCAB) was performed through a left thoracotomy. During normal cardiac contraction, a radial artery graft (RAG) was anastomosed sequentially from the descending aorta to the obtuse margin (OM) 1, OM2, RCA＃4PL (postero-lateral branch). The postoperative course was uneventful and he was discharged on the 26th post-operative day. In patients with patent grafts, re-median sternotomy has a high risk of injury to already patent grafts and adhesions make the dissection difficult. Alternatively, as in this case, off-pump coronary artery bypass through a left thoracotomy can be very effective. Total arterial vasoconstruction was performed and postoperatively there was no early graft occlusion.
　Jpn. J. Cardiovasc. Surg. 35: 85-88 (2006)

Simultaneous Cardiac Resynchronization Therapy and Cardiac Surgery in a Patient with Complete Right Bundle Branch Block (CRBBB), Left Posterior Hemiblock (LPH), and Aortic Valve Insufficiency

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

Takashi Miura	Imun Tei	Kazuki Sato
Takashi Oshitomi	Takafumi Hashimoto	Eiichi Tei

We performed cardiac resynchronization therapy (CRT) in addition to aortic valve replacement (AVR) in a 74-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 15%), complete right bundle branch block (CRBBB), left posterior hemiblock (LPH), and aortic valve insufficiency. 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. The New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in a patient with CRBBB and LPH can improve regional cardiac function and synchronicity.
　Jpn. J. Cardiovasc. Surg. 35: 89-94 (2006)

A Female Case of Abdominal Aortic Aneurysm in Association with Horseshoe Kidney

(Department of Cardiovascular Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Japan)

Toru Morimoto	Atsushi Ito	Teiji Jinno
Mamoru Tago

A 65-year-old woman was referred to our department for further examination and treatment of an abdominal aortic aneurysm. Preoperative abdominal 3-D CT revealed a horseshoe kidney with 2 aberrant renal arteries, arising from bilateral common iliac arteries and supplying blood to the renal lower poles. At operation, the abdomen was explored via a long midline incision. The abdominal aortic aneurysm was replaced with a knitted Dacron bifurcation graft without symphysiotomy, and the 2 aberrant renal arteries were preserved. Postoperative 3-D CT showed no sign of renal infarction or dysfunction. Abdominal 3-D CT was useful to reveal aberrant renal arteries of the horseshoe kidney.
　Jpn. J. Cardiovasc. Surg. 35: 95-97 (2006)

A Case of Traumatic Tricuspid Regurgitation with Cyanosis Caused by Patent Foramen Ovale

(Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Tochigi, Japan)

Yuhou Inoue	Yoshihiko Mochizuki	Yoshiei Shimamura
Motohiro Oshiumi	Yasuyuki Yamada	Yasushi Matushita
Kunihiro Eda	Shinichirou Miyoshi

A 47-year-old man was referred to our hospital for multiple rib fractures and pneumo-hemothorax due to a traffic accident. After admission, tricuspid valve regurgitation and hypoxemia were also diagnosed. Although fixation of the fractured ribs with plates and removal of hematoma in the pleural cavity were performed, hypoxemia did not improve. He was discharged on home oxygen therapy. Ten months and 3 years after the traffic accident, pulmonary perfusion scintigraphy suggested a right-to-left shunt. Transesophageal echocardiography demonstrated an opening of the foramen ovale and a right-to-left interatrial shunt. Direct closure of the patent foramen ovale and tricuspid valve replacement with the Carpentier-Edwards bioprosthesis were performed and hypoxemia disappeared after the second operation. Traumatic tricuspid valve regurgitation with cyanosis is extremely rare. However, it is important to take the possibility of patent foramen ovale into consideration in patients with traumatic tricuspid valve regurgitation and cyanosis.
　Jpn. J. Cardiovasc. Surg. 35: 98-101 (2006)

Trousseau Syndrome Caused by Ovarian Cancer and Nonbacterial Thrombotic Endocarditis in Aortic Valves

(Department of Cardiovascular Surgery, Saga Prefectural Hospital Koseikan, Saga, Japan)

Hisashi Sato	Hitoshi Ohteki	Kozo Naito
Junji Yunoki

A 45-year-old woman was admitted for acute left hemiplegia and left hypogastric pain. Central CT showed a right parietal lobe infarction. Abdominal CT demonstrated ovarian tumor and infarction of the liver, spleen and kidney. Chest radiography showed moderate cardiomegaly. Transthoracic echocardiography demonstrated vegetation in the aortic valves and severe aortic regurgitation. Aortic valve replacement and bi-adnexectomy were performed urgently. Intraoperative examination revealed normal aortic valves except for small amounts of vegetation on leaflet surfaces. Pathological diagnosis of vegetation was fibrin without inflammatory cells or bacteria. The postoperative course was uneventful, and the patient was discharged 13 days after surgery without a permanent neurological deficit. Trousseau syndrome caused by ovarian cancer and nonbacterial thrombotic endocarditis is rare, and it is important to be aware of this syndrome in the case of a young cerebral infarction patient with malignant disease.
　Jpn. J. Cardiovasc. Surg. 35: 102-105 (2006)

Gastrectomy after Coronary Artery Bypass Grafting with an In Situ Right Gastroepiploic Artery

(Department of Cardiovascular Surgery, Saga Prefectural Hospital Koseikan, Saga, Japan)

Hiroumi Kataoka	Hitoshi Ohteki	Kozo Naito
Junji Yunoki	Yousuke Ueno

A 73-year-old man presented with gastric adenocarcinoma 14 months after coronary artery bypass grafting with an in situ right gastroepiploic artery (RGEA) to left circumflex branch (LCx). He underwent a partial gastrectomy after successful percutaneous coronary intervention (PCI) to the occluded lesion of LCx. Though the RGEA graft was injured and sacrificed intraoperatively, gastrectomy was safely accomplished without any complication and the postoperative course was uneventful. Preoperative PCI was useful for a gastrectomy in a patient with an in situ RGEA.
　Jpn. J. Cardiovasc. Surg. 35: 106-108 (2006)

Mitral Valvuloplasty for Mitral Regurgitation in an Atypical Variant of Cardiac Fabry Disease

(Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan)

Atsushi Bito	Noboru Murata	Noboru Yamamoto

We report a case of mitral regurgitation due to an atypical variant of Fabry disease. A 60-year-old man was admitted to our hospital. He had a history of myocardial infarction and heart failure, and was repeatedly admitted for worsening heart failure (NYHA class II to III). A follow-up echocardiogram revealed deteriorating dilated cardiomyopathy and mitral regurgitation. We performed valvuloplasty for mitral regurgitation. Cardiomyopathy was suspected during the operation and myocardial biopsy was performed. We diagnosed Fabry disease by histopathological findings. After the operation, his heart failure temporarily improved. Heart failure worsened 4months later. He died of heart failure a year later from the operation. Fabry disease (α-galactosidase-A deficiency) is an inherited metabolic disease. In Fabry disease, angina, myocardial infarction, hypertrophic cardiomyopathy, dilated cardiomyopathy, and mitral regurgitation are common cardiac manifestations. Recently, an atypical variant of Fabry disease, with manifestations limited to the heart, has been increasingly reported. This case suggested that we might encounter Fabry disease with only cardiac manifestations such as cardiomyopathy and valvular disease in routine clinical work.
　Jpn. J. Cardiovasc. Surg. 35: 109-113 (2006)

A Case of Aortic Regurgitation Associated with Osteogenesis Imperfecta Successfully Treated by Aortic Valve Replacement

(Division of Cardiovasucular Surgery, Gunma Prefectural Cardiovascular Center, Maebashi, Japan and Second Department of Surgery, Gunma University Graduate School of Medicine*, Maebashi, Japan)

Norimasa Koike	Tatsuo Kaneko	Masahiko Ezure
Yasushi Sato	Masahiro Aizaki	Syuichi Okada
Yasuo Morishita*

A 51-year-old man with osteogenesis imperfecta and who had aortic regurgitation was admitted to our hospital for aortic valve replacement. His height was 146cm and his weight was 49kg. The patient had suffered from bone fractures several times since childhood. Bone deformity, blue sclera and his status were clinically indicative of osteogenesis imperfecta. Aortic valve replacement with a 25mm SJM^® prosthetic valve was successfully performed for aortic valve insufficiency and slight annulo-aortic ectasia. Soft tissues and the sternum were fragile. Pathological examination (Elastica-Masson stain) of the aortic valve and left ventricular wall revealed a loss of fibrous tissues and remarkable thickening due to elastic fibers. The patient was discharged 31days after surgery. Osteogenesis imperfecta is one of the collagen diseases caused by gene abnormality, in which fragile bones are easily fractured. Cardiovascular disease is rarely associated with it and the surgery-related mortality rate is reported to be approximately 30%, due to bleeding.
　Jpn. J. Cardiovasc. Surg. 35: 114-117 (2006)

Graft Infection in Femorofemoral Crossover Bypass, First Presenting as Septic Distal Emboli

(Department of Cardiovascular Surgery, Nagaoka Red Cross Hospital, Nagaoka, Japan)

Kenji Aoki	Hiroyuki Hirahara	Masaaki Sugawara
Fumiaki Oguma

We report a case of graft infection long after femorofemoral crossover bypas grafting (FFBG), first presenting as septic distal emboli without any infective signs in the groin. A 71-year-old man who had undergone FFBG visited our hospital because of sudden pain in his right foot. No infective signs were found in the graft route from physical examination. However, computed tomography demonstrated perigraft fluid and graft thrombi. Graft excision and extra-anatomic revascularization were successfully done. Light micrography showed Staphylococcus aureus extensively infiltrating in the expanded polytetrafluoroethylene graft wall.
　Jpn. J. Cardiovasc. Surg. 35: 118-121 (2006)

A Case Report of Type A Dissecting Aneurysm Occurring after Aortic Valve Replacement

(Department of Cardiovascular Surgery, Kawachi General Hospital, Higashiosaka, Japan)

Nobuo Sakagoshi	Takahiro Yamaguchi	Yasuhiko Kobayashi

We report a case of type A dissecting aneurysm occurring after aortic valve replacement (AVR). The patient was a 67-year-old man with a history of AVR 4 years previously. Preoperative CT scan revealed a type A dissecting aneurysm 10cm in diameter, close to the sternum. Under preparation for selective cerebral perfusion (SCP), re-do median sternotomy was safely performed using partial extracorporeal circulation (ECC) via a femoral artery and vein. Because of severe adhesion in the upper part of the ascending aorta and aortic arch, a graft replacement of the ascending aorta was impossible. Under SCP via bilateral common carotid arteries exposed in the neck, the entry of the dissection, which was located in the previous aortotomy line, was closed with an ePTFE patch. SCP via bilateral common carotid arteries exposed in the neck appeared to be very useful and safe for such patients at risk for injury to the aorta during re-do median sternotomy and with severe adhesion, which made it difficult to establish SCP via the usual operative field. Although graft replacement is the standard operation for the treatment of the ascending aortic dissection, patch closure of the entry should be considered as a second-choice method in some case.
　Jpn. J. Cardiovasc. Surg. 35: 122-125 (2006)