Japanese Journal of Cardiovascular Surgery Vol.35, No.3

Vacuum-Assisted Closure for Infections after Cardiovascular Surgery

(Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Japan and Department of Plastic Surgery, Nagahama Red Cross Hospital*, Nagahama, Japan）

Ryuji Higashita	Tohru Asai	Shoichiro Shiraishi
Keiji Matsubayashi	Takao Nishi	Masato Kurokawa*

We employed vacuum-assisted closure (VAC) as a treatment modality for wound complications after cardiovasular surgery. Between March and December 2004, 9 patients were treated with VAC, 8 of whom were men, and the mean age was 69.6 years old. Seven patients underwent off-pump coronary artery bypass, and 2 underwent a valve replacement. Six of them had diabetes, 5 had renal dysfunction (4 were dialysis patients), and 2 had chronic obstructive lung disease. Six cases were classified as superficial sternal infection (Superficial) and 3 as a deep sternal infection (Deep). Superficial cases were healed with wound closure after a short period of VAC treatment. However, Deep cases required long duration of VAC treatment and wound closure with a myocutaneous flap in 2 cases, although all of them did not develop mediastinitis requiring closed irrigation and drainage. In 9 cases, with numerous risk factors for poor healing, we found that VAC treatment facilitated wound healing and reduced frequent painful wound care.
　Jpn. J. Cardiovasc. Surg. 35: 127-131 (2006)

Surgical Treatment for a Trauma-Caused Cardiac Rupture

(Department of Thoracic Surgery, University of Saga, Saga, Japan)

Manabu Itoh	Kojiro Furukawa	Yukio Okazaki
Satoshi Ohtsubo	Junichi Murayama	Shugo Koga
Tsuyoshi Itoh

The survival rate of patients with cardiac rupture due to a blunt trauma is low, therefore it is necessary to have a well-defined diagnostic and treatment plan in order to improve the survival rate. In 8 such patients transthoracic echocardiograms at the time of arrival at our hospital showed pericardial effusion with cardiac tamponade in all patients. The mean time between suffering the injury and arriving at the hospital was 186±185 min, and the mean time between arrival and being brought to the operating room was 82±49 min. Preoperative pericardial drainage was performed in 2 patients, and percutaneous cardiopulmonary support system was used in 2 patients. The rupture site was in the right atrium in 3 patients, the right atrium-inferior vena cava in 1 patient, the right ventricle in 2 patients, the left atrium in 1 patient, and the left ventricle in 1 patient. Extracorporeal circulation was used in 4 patients, and the injured site was repaired. We were thus able to save the lives of 6 of the 8 patients (survival rate 75%). Transthoracic echocardiography was easy to perform and effective for making an accurate diagnosis. Many such patients tend to have multiple traumas, but, if the patient is in a state of shock due to cardiac tamponade, the patient should be moved immediately to the operating room. It is important to provide circulatory maintenance until surgery, and pericardial drainage and PCPS are also effective additional treatment modalities..
　Jpn. J. Cardiovasc. Surg. 35: 132-135 (2006)

Myonephropathic Metabolic Syndrome following Femoral Arterial Cannulation

(Department of Cardiovascular Surgery, National Disaster Medical Center, Tachikawa, Japan)

Saeki Tsukamoto	Shoji Shindo	Shinsuke Choh

Between 1999 and 2004, 337 cardiovascular surgical procedures using cardiopulmonary bypass were conducted in our institution. Femoral arterial cannulation was performed in 130 cases (38.6%) and 3 of these cases, all men aged under 60, developed compartment syndrome in the ipsilateral leg. The ischemic time of the leg was between 240 and 294 min. Two of them developed myonephropathic metabolic syndrome (MNMS) and underwent continuous hemodiafiltration. Two of the cases were ambulant on discharge from hospital but one died. Compartment syndrome and MNMS are serious complications, and must be prevented rather than treated. Young male patients are at increased risk of these complications, and are often reported in Japan. In order to prevent leg ischemia during femoral cannulation, care should be taken not to disrupt deep femoral arterial flow (which is the collateral inflow) or superficial femoral arterial flow. When back flow from the profunda femoris artery is inadequate, peripheral perfusion should be performed to avoid leg ischemia..
　Jpn. J. Cardiovasc. Surg. 35: 136-139 (2006)

CABG in a Patient with the Human Immunodeficiency Virus

(Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Japan and Department of Cardiothoracic Surgery, Graduate School of Medicine, Nagoya University*, Nagoya, Japan)

Masato Mutsuga	Shuji Tamaki	Yukifusa Yokoyama
June Yokote*	Naoyoshi Ishimoto

HIV infection is an extremely serious problem, and the number of HIV-infected patients is increasing in the world. The introduction of highly active antiretroviral therapy (HAART) and protease inhibitors (PI) allows maintenance of the inhibition of viral replication and partial reinstating the immune system in most patients. As HIV has changed from a progressive fatal illness to a chronic condition, many infected patients increasingly require diverse health services including cardiac surgery. We report a case of a 68-year-old man with HIV infection who underwent successful coronary artery bypass grafting using a cardiopulmonary bypass. The operative indication were determined according to the CD4 count and the amount of HIV-RNA. Standard precautions were taken in the same way as for hepatitis B and hepatitis C cases. There was no percutaneous exposure to HIV infected blood. The postoperative course was uneventful, and the patient was discharged with no complications of HIV. The patient has been quite well without any therapy for HIV over one year.
　Jpn. J. Cardiovasc. Surg. 35: 140-143 (2006)

A Case of Reoperation for a Starr-Edwards Ball Valve Prosthesis Implanted in the Aortic Position 30 Years Previously

(Department of Cardiothoracic Surgery, Fujieda Municipal General Hospital, Fujieda, Japan)

Naoyuki Ishigami	Kimitoshi Horiba

The patient was a 57-year-old woman. In 1974, she had undergone aortic valve replacement using a Starr-Edwards ball valve to treat aortic stenosis at another hospital. In 1989, she had undergone percutaneous transluminal mitral commissurotomy (PTMC) for mitral stenosis at our hospital. In December 2003, she was admitted with cardiac failure of NYHAⅢ to our hospital. Echocardiography showed the progressive changes of mitral stenosis and the prosthetic aortic valve. In January 2004, the mitral valve was replaced using a CarboMedics prosthesis and the Starr-Edwards aortic valve was replaced using a BICARBON prosthesis, together with tricuspid ring annuloplasty. The cloth wear of the Starr-Edwards valve cage and a pannus formation at the valve seat was found at operation. The patient was discharged, and now is rehabilitated in good health.
　Jpn. J. Cardiovasc. Surg. 35: 144-146 (2006)

Mediastinitis following Graft Replacement of the Ascending and Total Arch Aorta in Two Cases

(Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Japan)

Atsushi Tamura	Yoshiharu Takahara	Kenji Mogi
Masayoshi Katsumata

Mediastinitis following graft replacement of the ascending and total arch aorta is a fatal complication of cardiac surgery. When graft infection is suspected, one choice of treatment is to remove the infected prosthesis and replace it with a new one. However such a procedure seems to be very risky. We report 2 successfully treated cases of mediastinitis following graft replacement of the ascending and total arch aorta. In one case, we treated with primary sternal closure after debridement and omental flap implant. In another case, the wound was left open and irrigation with iodine solution was undertaken for 6 days. The sternum was closed with pectoralis major muscle flap implantation. When graft infection is not suspected, primary sternal closure with implantation of tissue flaps is recommended. When graft infection is strongly suspected, we prefer secondary sternal closure after open irrigation.
　Jpn. J. Cardiovasc. Surg. 35: 147-150 (2006)

Correction of Severe Ebstein’s Anomaly in a Neonate with Pulmonary Atresia

(Department of Cardiovascular Surgery, Saiseikai-Shimonoseki General Hospital, Shimonoseki, Japan)

Toshiro Kobayashi	Kenji Hayashi	Kensuke Sakata
Yurio Kobayashi

We report the successful surgical treatment of severe Ebstein’s anomaly in a female neonate with pulmonary atresia. Soon after birth, a heart murmur was audible and the baby became cyanotic. Echocardiography showed Ebstein’s anomaly with pulmonary atresia. We started a LipoPGE1 infusion for the open ductus arteriosus, but her uncontrollable heart failure necessitated surgery. Thus, when she was 8 days old, she was placed on cardiopulmonary bypass and we performed a triuspid valve orifice closure with right atrium plication and enlargement of the interatrial communication. She received a modified Blalock-Taussig shunt at the age of 60 days, but a prolonged mirulinone infusion was needed for her persistent heart failure. When she was 10 months old, we inserted a bidirectional Glenn shunt and she was discharged. Finally, when she was 30 months old, she had a total cavopulmonary connection. The patient is now asymptomatic, 18 months after her last operation.
　Jpn. J. Cardiovasc. Surg. 35: 151-154 (2006)

A Case of Ostial Stenosis of the Left Main Coronary Artery and Aortic Valve Insufficiency due to Syphilitic Aortitis―Surgical Ostial Angioplasty with Fresh Autologous Pericardium―

(Department of Cardiovascular Surgery, Oji General Hospital, Tomakomai, Japan)

Tomonori Ooka	IYutaka Makino	Tatsuya Murakami

We report a case of surgical ostial angioplasty with fresh autologous pericardium concomitant with aortic valve replacement for ostial stenosis of the left main coronary artery (LMT) with aortic valve insufficiency due to syphilitic aortitis (SA). A 50-year-old man with chronic atrial fibrillation and a history of multiple cerebral infarctions was found to have a 90% ostial stenosis of the LMT with an intact distal coronary artery tree. On preoperative echocardiography, severe aortic valve insufficiency and left atrial thrombus were noted. A chest CT showed no thickening or dilatation of the ascending aorta and no calcification of the aortic root and LMT. As a serological syphilitic test, the treponema pallidum hemagglutination test was positive in 1: 10,387 dilution with a positive rapid plasma reagin method. He had no chest pain or fever. At surgery, gross thickening and fibrosis of the ascending aortic wall extending from the aortic root was noted, suggesting aortitis such as Takayasu aortitis and SA. The aortic valve was replaced with a mechanical valve and the LMT was successfully enlarged with a fresh autologous pericardial patch, confirmed by postoperative coronary angiography. Pathological findings of the aortic wall and the valve were consistent with SA, where treponema pallidum was found immunohistologically. He had an uneventful postoperative course and was treated with a 3.5-month course of amoxicillin (750mg/day) for cardiovascular syphilis. Although SA is rarely seen nowadays, we should consider the possibility of this disease if there is a combination of coronary ostial stenosis and aortic valve insufficiency. Since surgical coronary ostial angioplasty has never been applied for SA, a careful observation is required.
　Jpn. J. Cardiovasc. Surg. 35: 155-159 (2006)

Pseudoaneurysm in the Ascending Aorta as a Late Complication in a Case of Cardiac Surgery

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

Fumiaki Kuwabara	Yuichi Hirate	Tomo Sugiura
Akira Takanohashi	Kei Yagami	Naoyoshi Ishimoto
Masaharu Yoshikawa	Tadahiko Asai	Yoshiya Miyata

A 52-year-old man had a history that included aortic valve replacement due to infectious endocarditis in 1987. Chest X-ray showed slight enlargement of the superior mediastinum in 1998, but the enlargement was very mild and there had not been any significant change since 1998. However, chest X-ray demonstrated an extremely protruding mass on the right side of the superior mediastinum in May 2004 and a pseudoaneurysm located in the ascending aorta was demonstrated by computed tomography. We considered this aneurysm had been caused by ascending aortic cannulation for blood return from cardiopulmonary bypass (CPB) during the previous surgery. On re-operation, CPB was established by femoro-femoral bypass and median sternotomy was performed. The pseudoaneurysm measured 60mm in diameter and there was a felt-pledget on top of the aneurysm. Under deep hypothermic cardiac arrest, we incised the aneurysm and closed the orifice of the pseudoaneurysm using a patch (Hemashield Woven Fabrics). On pathological examination, the wall of the pseudoaneurysm showed a structural loss of the blood vessel and the felt-pledget had been exposed to the inferior of the aneurysm breaking through the wall. We considered this a non-mycotic pseudoaneurysm because of this patient’s clinical course, surgical and pathological findings. We encountered a pseudoaneurysm in the ascending aorta that was detected and treated surgically about 20 years after aortic valve replacement.
　Jpn. J. Cardiovasc. Surg. 35: 160-163 (2006)

A Case of Mycotic Pseudoaneurysm of the Brachiocephalic Artery

(Yokohama City University Medical Center Cardiovascular Center, Yokohama, Japan and First Department of Surgery, Yokohama City University*, Yokohama, Japan)

Motohiko Goda	Kiyotaka Imoto	Shinichi Suzuki
Keiji Uchida	Toshiki Hatsune	Yoshinori Takanashi*

A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed Staphylococcus aureus. A mycotic pseudoaneurysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2 cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.
　Jpn. J. Cardiovasc. Surg. 35: 164-167 (2006)

Double Valve Replacement for Severe Insufficiency of the Aortic and Mitral Valves in an Adult with Left Ventricular Noncompaction

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

Hiromichi Sonoda	Kunihiko Jouo	Masayoshi Umesue
Koji Matsuzaki	Kanzi Matsui

Left ventricular noncompaction (LVNC) is believed to represent an arrest in the normal process of myocardial compaction, resulting in persistence of both hyper-trabeculation and intra-trabecular recess within the left ventricle. High mortality is the important clinical feature of this disease. LVNC in adult cases has been rarely, but occasionally, reported, however, LVNC with insufficiency of both the aortic and mitral valves has not been reported to our knowledge. Herein, we describe a 62-year-old man with LVNC and the severe insufficiency of the aortic and mitral valves, who was successfully operated upon with aortic and mitral valve replacement using mechanical valves. Although the postoperative course was uneventful, careful attention is mandatory for the possible left ventricular dysfunction due to LVNC.
　Jpn. J. Cardiovasc. Surg. 35: 168-172 (2006)

Cerebrospinal Fluid Drainage as a Useful Treatment to Relieve Paraplegia Caused by Acute Type A Aortic Dissection

(Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Fukushima, Japan)

Kouki Takahashi	Hirono Satokawa	Toshizumi Shirai
Yoichi Sato	Takashi Ono	Shinya Takase
Hiroki Wakamatsu	Yoshiyuki Sato	Hitoshi Yokoyama

We report a rare case of acute type A aortic dissection with paraplegia which was reversed using cerebrospinal fluid drainage (CFD). The patient was a 80-year-old man who was admitted with acute back pain and paraplegia. Computed tomographic scans showed an acute type A aortic dissection. Four hours after onset of paraplegia, CFD was initiated by inserting an intrathecal catheter at L3-L4. Cerebrospinal fluid was drained freely by gravity whenever the pressure exceeded 10cmH₂O. After 32h, the neurological deficit was completely resolved. CFD can be considered a useful treatment in patients with paraplegia after acute aortic dissection.
　Jpn. J. Cardiovasc. Surg. 35: 173-176 (2006)

Simultaneous Cardiac Resynchronization Therapy and Mitral Valve Replacement in a Patient with Dilated Cardiomyopathy

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

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

We performed cardiac resynchronization therapy (CRT) in addition to mitral valve replacement (MVR) in a 66-year-old patient with dilated cardiomyopathy (DCM) associated with complete left bundle branch block (CLBBB) and mitral valve insufficiency. Tissue Doppler echocardiography showed synchronicity of the septum and lateral wall in the left ventricle after CRT. New York Heart Association functional class improved from III to I after CRT and MVR. CRT of the dyssynchronic myocardium in a patient with DCM associated with CLBBB improves regional cardiac function and synchronicity.
　Jpn. J. Cardiovasc. Surg. 35: 177-182 (2006)

Surgical Treatment for Infective Endocarditis in a Case with Bicuspid Aortic Valve and Dilated Ascending Aorta

(Department of Surgery and Department of Surgical Pathology*, Faculty of Medical Sciences, University of Fukui, Fukui, Japan)

Sawaka Tanabe	Kuniyoshi Tanaka	Akio Ihaya
Koichi Morioka	Takahiko Uesaka	Wei Li
Narihisa Yamada	Atsushi Takamori	Mitsuteru Handa
Yoshiaki Imamura*

A 51-year-old man developed a high fever with congestive heart failure after treatment for his dental caries and was admitted to our hospital. Transesophageal echocardiogram showed severe aortic regurgitation with a bicuspid aortic valve where vegetation and perforation was identified on its leaflets. Infective endocarditis caused by Streptococcus constellatus was diagnosed by blood culture. A computed tomography scan of the chest showed enlargement of his ascending aorta with a maximum diameter of 5.0cm. After treatment with antibiotics and diuretics for 60 days, he underwent surgical treatment for his aortic valve and ascending aorta. After excising the diseased aortic leaflets with vegetation, a mechanical prosthetic valve (Carbomedicus 23mm) was implanted. His ascending aorta was also replaced separately with a woven Dacron tube graft. There was an anomalous origin of the right coronary artery which was detached from the ascending aortic wall as a button and was implanted on the tube graft. Histologically the aortic wall showed disappearance of elastic fibers with myxomatous degeneration in the media. Immunohistochemical staining also revealed that matrix metalloproteinase-2 (MMP-2) was strongly expressed in the aortic media. The postoperative course was uneventful and he was discharged on the 37th postoperative day.
　Jpn. J. Cardiovasc. Surg. 35: 183-187 (2006)

Surgical Repair of Double Outlet Right Ventricle and Coarctation of the Aorta in a Neonate with a Right Aortic Arch

(Department of Cardiovascular Surgery, Yokohama City University School of Medicine, Yokohama, Japan)

Yoshifumi Kunii	Keiichiro Kasama	Motohiko Goda
Hiroharu Hikawa	Yukihisa Isomatsu	Masatsugu Terada
Yoshinori Takanashi

Coarctation of the aorta (CoA) complicates with right aortic arch (RAA) is very rare, and its surgical treatment in the neonatal period is extremely uncommon. We performed surgical repair for a 27-day-old boy given a diagnosis of double outlet right ventricle (DORV) and CoA with RAA. The procedures consisted of an arterial switch, intra-ventricular re-routing, aortic arch reconstruction using an equine-pericardial roll and right ventricular outflow reconstruction (RVOTR) with autologous pericardium. We performed re-RVOTR 41 days after the operation because the autologous pericardium used for RVOTR showed aneurysmal dilatation. After the second operation, this patient has done well.
　Jpn. J. Cardiovasc. Surg. 35: 188-191 (2006)