Japanese Journal of Cardiovascular Surgery Vol.35, No.4

Early Results of Left Ventricular Reconstruction for Ischemic Cardiomyopathy with Severe Left Ventricular Dysfunction

(Department of Cardiovascular Surgery, Kochi Health Sciences Center, Kochi, Japan)

Satofumi Tanaka	Manabu Okabe	Jin Tanaka
Yoichiro Miyake	Iwao Hioki	Takemi Handa

Left ventricular reconstruction methods (LVR) consisting of the Dor procedure or septal anterior ventricular exclusion (SAVE) have been advocated for left ventricular dysfunction due to ischemic cardiomyopathy (ICM). This study reports early results achieved with LVR in patients with ICM. Between April 2001 and August 2004, 9 patients with ICM underwent LVR and coronary artery bypass grafting (CABG). Their age was 62±11 years, and 7 were men. The Dor procedure was performed in 8 patients and 1 patient underwent SAVE. CABG was performed in all patients. Two patients with grade 3 mitral regurgitation (MR) preoperatively had mitral valve annuloplasty (MAP). The mean left ventricular ejection fraction (LVEF) improved from 31.6±7.2% to 47.8±9.4%. The mean left ventricular end diastolic volume index (LVEDVI) decreased from 166.7±50.4ml/m² to 102.6±23.0ml/m². The mean left ventricular end systolic volume index (LVESVI) decreased from 114.4±34.7ml/m² to 52.4±16.6ml/m². The mean coaptation depth decreased from 9.3±3.1mm to 4.5±1.4mm. The mean MR, with or without MAP, improved from grade 1.7±1.1 to grade 0.2±0.4. There were no hospital deaths. Seven of 9 patients were categorized as New York Heart Association functional class I at discharge. We conclude that LVR is an effective treatment for ICM with severe left ventricular dysfunction.
　Jpn. J. Cardiovasc. Surg. 35: 193-197 (2006)

Role of 16-Slice Multi-Detector Row Computed Tomography in Surgical Management of Congenital Heart Disease

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

Ken Nakamura	Kiyozou Morita	Yosihiro Ko
Yoko Matsumura	Katsushi Kinouchi	Kazuhiro Hashimoto

Preoperative evaluation of cardiac anatomy is essential to determine the correct surgical procedure for congenital heart disease. Multi-detector row CT (MDCT) is a useful alternative imaging modality to cardiac catheterization and echocardiography. Sixteen patients (12 with total anomalous pulmonary venous return (TAPVR) and 4 with aortic arch anomalies) underwent 16-slice multi-detector row CT scanning. Three-dimensional reconstruction by MDCT was useful to determine the type of TAPVR and the presence of pulmonary venous obstruction (PVO) in TAPVR patients, as well as to detect postoperative PVO in patients who underwent intracardiac repair. In 2 patients who had asplenia associated with TAPVR III and I a, MDCT enabled an intra-atrial approach for TAPVR repair by precise preoperative determination of the relationship between the common PV chamber and single atrium . In patients with aortic arch anomalies, MDCT was useful to determine the type of anomaly, the presence of arch hypoplasia, and any associated rare vascular anomalies (including isolated subclavian artery, and the right-sided descending aorta with left aortic arch). In conclusion, MDCT provides reliable preoperative evaluation of pulmonary venous return and aortic arch anatomy, and therefore is extremely useful for surgical management of congenital heart disease.
　Jpn. J. Cardiovasc. Surg. 35: 198-204 (2006)

A Case of Aortopulmonary Window after Balloon Angioplasty for Bifurcation Pulmonary Stenosis Based on the Jatene Procedure

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

Ken Nakamura	Kiyozou Morita	Yoshihiro Ko
Katsushi Kinouchi	Kazuhiro Hashimoto

A 6-month-old baby boy had undergone the Jatene procedure at 4 days. Four months later, catheter intervention (balloon angioplasty) was performed because of severe stenosis at the bifurcation of the pulmonary arteries. Twenty days later, several episodes of cyanosis occurred and he was readmitted. The existence of shunt flow between the sinus of valsalva and the pulmonary bifurcation was detected by echocardiography and examination by 16-row MDCT revealed 2 holes at this site. Under a diagnosis of aortopulmonary (AP) window, the patient was placed on cardiopulmonary bypass and the pulmonary artery was opened after aortic clamping. There was a ridge between the bifurcation of the pulmonary arteries. After removing it, 2 holes were visualized that resembled the findings on 16-row MDCT. These holes were closed with Xenomedica patches and the main pulmonary artery was also extended with a Xenomedica patch. AP window is a rare complication after balloon angioplasty for pulmonary stenosis, but we must take great care to prevent this complication.
　Jpn. J. Cardiovasc. Surg. 35: 205-209 (2006)

A Ruptured Anterior Tibial Artery Aneurysm in a Patient with von Recklinghausen's Disease

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

Shuichi Shiraishi	Kenji Aoki	Hiroshi Amano
Yoshiki Takahashi	Satoshi Nakazawa	Hiroshi Kanazawa

A 41-year-old woman with neurofibromatosis (NF) was admitted to our hospital for severe pain and right leg swelling of 5days duration. Paralysis of the right leg due to compartment syndrome was also recognized. She had been diagnosed as von Recklinghausen's neurofibromatosis, previously. 3D-computed tomography showed a ruptured anterior tibial artery aneurysm. There was a normal patent posterior tibial artery. Since her complaint of pain was severe, we performed an emergency operation. Under the pneumatic tourniquet technique, the aneurysm was resected, and both the proximal and distal sides of the anterior tibial artery were ligated. A massive hematoma was completely removed. Postoperatively, the dorsalis pedis and posterior tibial pulses remained palpable. The paralysis improved considerably and she was given an ambulatory discharge from our hospital 21days after the operation. Histological examination revealed proliferating wavy spindle cells infiltrating between the adventitia and mesothelium of the aneurysmal wall and staining positively for S100 immunoperoxidase.
　Jpn. J. Cardiovasc. Surg. 35: 210-212 (2006)

Case of Unruptured Aneurysm of the Sinus of Valsalva into the Right Atrium with Perimembranous VSD

(Department of Cardiac Surgery, Aichi Medical University, Aichi, Japan and Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine*, Nagoya, Japan)

Takahiko Aoyama	Kengo Kimura	Chihiro Narumiya
Masaya Hirai	Osamu Kawaguchi	Yoshihisa Nagata
Yuichi Ueda*

An 8-year-old girl had been found to have a congenital ventricular septal defect (VSD), based on the presence of a cardiac murmur from birth. She had a history of infective endocarditis and lung abscess when she was 2 years old. Mild aortic regurgitation was revealed by an echocardiogram in August 2004. Right-heart catherization revealed a step up in the oxygen saturation of the right ventricle, aortography showed a deformity of the noncoronary cusp and mild aortic regurgitation, and Doppler color-flow echocardiography detected progression of aortic regurgitation. The patient underwent surgical repair of the VSD with a cardiopulmonary bypass. Following direct suturing combined with pledgets for perimembranous VSD, infusion of cardioplegia revealed the aneurysmal sac extruding from the wall of the right atrium. The final diagnosis was an aneurysm of the sinus of Valsalva from the noncoronary aortic sinus into the right atrium (type IV of Konno). The aneurysm was sutured by polyethylene strings with pledgets. The postoperative course was uneventful, and echocardiography performed before discharge showed no deformity of the sinus of Valsalva and trivial aortic regurgitation which was less than before surgery. She was discharged on the 7th postoperative day.
　Jpn. J. Cardiovasc. Surg. 35: 213-216 (2006)

Separate Perfusion of the Upper and Lower Body under Different Temperatures during Thoracoabdominal Aortic Aneurysm Repair in a Patient with Low Left Ventricular Function

(Department of Cardiovascular Surgery, Hamamatsu Medical Center, Hamamatsu, Japan and Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine*, Tsu, Japan)

Kiyohito Yamamoto	Hisato Itou	Yasuhiro Sawada*
Takane Hiraiwa	Hiroshi Hata

A 79-year-old man was admitted for thoracoabdominal aortic aneurysm repair. He had already twice undergone coronary artery bypass grafting, 19 and 2 years previously. The value of the ejection fraction of the left ventricle was 36%, measured by ventriculography; and transthoracic echocardiography revealed moderate aortic valve regurgitation. In the presence of aortic valve regurgitation or coronary artery disease, myocardial perfusion under hypothermic fibrillatory arrest may be significantly impaired. Therefore, to maintain a beating heart we used separate perfusions of the upper and lower body that enabled individual temperature control of each organ. The femoral and axillary arteries were cannulated, and a long cannula was inserted into the right common femoral vein and positioned in the right atrium. Cardiopulmonary bypass was established, and the upper body was mildly cooled until the pharyngeal temperature was 33℃, while the lower body was cooled until the bladder temperature reached 20℃. Mild hypothermia of the upper body maintained the beating heart, and deep hypothermia in the lower body provided adequate protection to the spinal cord. Furthermore, in a case of aortic valve regurgitation and low left ventricular function, left ventricular venting is essential for the heart. However, it was difficult to insert the venting tube through the apex of the left ventricle or through the left inferior pulmonary vein; therefore, we selected the left main pulmonary artery for left ventricular venting, and maintained a non-working beating heart. After cardiopulmonary bypass was discontinued, cardiac function was good although a bleeding tendency became apparent. Postoperatively, the maximum dose of dopamine we needed was only 3γ. There were no remarkable complications and the patient was discharged on postoperative day 30. This experience suggests that pulmonary artery venting and separate perfusion of the upper and lower body to individually control organ temperatures is a useful procedure for thoracoabdominal aortic aneurysm repair in patients with low left ventricular function.
　Jpn. J. Cardiovasc. Surg. 35: 217-221 (2006)

A Case of Heparin-Induced Thrombocytopenia (HIT) following Aortic Surgery for Acute Type A Aortic Dissection

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

Masayoshi Katsumata	Yoshiharu Takahara	Kenji Mogi
Atsushi Tamura

A 44-year-old man underwent total arch replacement for acute type A aortic dissection. He was treated postoperatively in the intensive care unit for acute renal failure and respiratory failure. Although recovery of organ functions was seen, an unexpected fall in platelet count (PLT) occurred abruptly on postoperative day (POD) 7. The patient was treated with gabexate mesilate and platelet transfusion because disseminated intravascular coagulation (DIC) was initially suspected. Nevertheless, PLT dropped rapidly below 1.0×10⁴/μl. We suspected heparin-induced thrombocytopenia (HIT) and stopped all heparin administration including flush solution for pressure monitoring lines. The platelet factor 4-reactive HIT antibody test was performed and we began to give intravenous argatroban, 60mg/day. However, PLT did not increase at all. Multiple organ failure developed and metabolic acidosis deteriorated rapidly resulting in death on POD15. HIT antibody was positive on POD13 and a definitive diagnosed of HIT was made. For those patients treated with heparin continuously or repeatedly, HIT may occur and increase the mortality risk if the diagnosis is delayed.
　Jpn. J. Cardiovasc. Surg. 35: 222-225 (2006)

Replacement of an Infected Prosthetic Graft with an Autogenous Superficial Femoral Vein: A Report of Two Cases

(Department of Cardiovascular Surgery, Kanazawa Medical University, Ishikawa, Japan)

Hiroo Shikata	Yasuhisa Noguchi	Takashi Kobata
Kenji Hida	Shigeru Sakamoto	Junichi Matsubara

We experienced the usefulness of the superficial femoral vein as an autogenous graft replacement of an infected prosthetic graft. Case 1: A 75-year-old man complained of right leg intermittent claudication due to arteriosclerosis. Prosthetic femoro-femoral crossover bypass was performed. Three months after the operation, prosthetic bypass graft infection was diagnosed. Case 2: A 72-year-old man underwent an aortobifemoral graft surgery for an abdominal aortic aneurysm (5cm in diameter). Ten days after the operation, the patient suddenly had a high fever and bacterial culture of the blood demonstrated Gram-negative bacilli. Prosthetic bypass graft infection was diagnosed. Both cases were resistant to conservative therapies including antibiotics. The infected prosthetic grafts were removed and autogenous reconstructions were performed extra-anatomically using the superficial femoral vein: in Case 1, with femoro-femoral crossover bypass, and in Case 2, with axillo-unifemoral bypass with anastomosis of bilateral common iliac arteries. Both infections eventually resolved. Since the deep femoral vein had been preserved during harvesting of the superficial femoral vein, no problems, such as venous congestion of the leg, occurred in either of the two cases. Their postoperative courses were uneventful and the patients were given ambulatory their own feet. We reviewed the literature about the utility of superficial femoral veins as arterial substitutes.
　Jpn. J. Cardiovasc. Surg. 35: 226-230 (2006)

Rupture of the Inferior Vena Cava Associated with CompleteThrombotic Occlusion after Placement of a Caval Filter

Ken-ichi Imasaka	Masahiro Oe	Shin-ichiro Oda

We reported a case of a 41-year-old woman with a ruptured inferior vena cava (IVC): this was revealed by a swelling in the lower extremities and bursting pain. This condition was diagnosed on laparotomy. The operation involved repair of the IVC tear and thrombectomy. In this patient, a permanent IVC filter had been placed previously due to deep vein thrombosis. The head of the IVC filter had been covered by a fibrous membrane. Entrapment of the thrombus in the IVC filter might have resulted in high venous pressure in the IVC and a subsequent predisposition of the IVC to rupture. The swelling in the legs diminished slowly, and the patient was discharged with oral anticoagulation and elastic stockings. Despite clinical features and computed tomography findings, the physician's awareness of this disease remains the most important factor for early treatment.
　Jpn. J. Cardiovasc. Surg. 35: 231-234 (2006)

A Recovery Case of Severe Heart Failure after Emergency Coronary Artery Bypass Grafting Supported by a Left Ventricular Assist System

(Department of Cardiovascular Surgery, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan)

Yuhei Saitoh	Masaki Aota	Takahide Takeda
Takeichiro Nakane	Yutaka Konishi

In general strategy for postcardiotomy heart failure includes inotropic support followed by the use of an intra-aortic balloon pump and percutaneous cardiopulmonary bypass support（PCPS). The insertion of a ventricular assist system（VAS）may become necessary when these procedures fail to restore hemodynamic stability. The ABIOMED BVS5000 left ventricular assist support system（LVAS）has been approved for clinical use in Japan since 1998. Here we describe our experience with the recovery of a 52-year-old man from postcardiotomy heart failure after using an ABIOMED BVS5000 LVAS. The patient was admitted to our institution with dyspnea. Heart failure with severe left ventricular dysfunction was diagnosed, and recent myocardial infarction was suspected from his history and electrocardiogram. Two days after admission, ventricular fibrillation occured and the arrythmia was hard to control. PCPS was connected and emergency coronary angiography showed triple vessel disease. We performed emergency coronary artery bypass grafting with the heart beating under PCPS and immediately implanted an ABIOMED BVS5000 device to achieve myocardial recovery after stopping PCPS. He was weaned from the LVAS at 6 days after surgery. His postoperative course was relatively uneventful and he was discharged after recovery.
　Jpn. J. Cardiovasc. Surg. 35: 235-238 (2006)

A Case of Aortoduodenal Fistula Presenting Six Years after an Operation for Abdominal Aortic Aneurysm

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

Yasuhiro Sawada	Hitoshi Kusagawa	Kouji Onoda
Takatsugu Shimono	Hideto Shinpo

A 74-year-old man who had received graft replacement of ruptured abdominal aortic aneurysm 6 years previously was admitted to our hospital because of hematemesis. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Preoperative CT scan demonstrated an adhesion of the aorta-duodenum at the proximal anastomosis of the prosthetic graft. Preoperative angiography demonstrated no leak of contrast material at the proximal anastomosis of the prosthetic graft. Therefore, we performed an emergency operation under a diagnosis of an aortoduodenal fistula. Operative reconstruction was performed with in situ grafting using a new prosthetic graft, and the greater omentum was used to fill defects surrounding the anastomotic site. We report a case of surgical treatment for an anastomotic aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair.
　Jpn. J. Cardiovasc. Surg. 35: 239-241 (2006)

Successful Surgical Treatment of Traumatic Rupture of the Descending Aorta in a Child

(Department of Cardiovascular Surgery, Okazaki City Hospital, Okazaki, Japan and Department of International Health, Graduate School of Medicine, Nagoya University*, Nagoya, Japan)

Takeshi Yuasa	Leo Kawaguchi*	Yasuhisa Ohara
Kenzo Yasuura

Traumatic rupture of the thoracic aorta is extremely rare in pediatric patients. We present a case of blunt traumatic aortic disruption in a 13-year-old boy who was successfully managed by patch aortoplasty using cardiopulmonary bypass. He was involved in a motor vehicle accident. He had a transient loss of consciousness. Initial vital signs were stable. Upon arrival at our hospital he was awake, alert, and oriented. Chest roentgenogram showed a subtly widened upper mediastinum with left pleural effusion. Chest computed tomography revealed a hematoma around the transverse and proximal descending thoracic aorta, and a 25-mm pseudoaneurysm with the intimal flap in the proximal descending thoracic aorta. Aortography verified a partial transection of the proximal descending aorta. Within 4h after injury, aortic repair was initiated through a left anterolateral thoracotomy. Following heparinization, partial cardiopulmonary bypass was established via the right femoral artery and vein. Sequential occlusion of the left subclavian artery, aortic arch between the left carotid and subclavian arteries, and descending aorta was performed. The periaortic hematoma was incised longitudinally to show a transverse tear involving the anterolateral aortic wall 3cm distal to the origin of the left subclavian artery. The disruption involved approximately 90% of the circumference of the aortic wall and there was retraction of the torn edges. A half of the impaired aorta was sutured, primarily to accommodate future aortic growth, and the other half of the defect was closed with a prosthetic patch. Bypass time was 173min. The postoperative course was complicated by persistent low-grade fever and hoarseness. Four years following discharge, he was well with only slight hoarseness, and magnetic resonance angiography two years later demonstrated a normal aorta without clinical evidence of coarctation.
　Jpn. J. Cardiovasc. Surg. 35: 242-245 (2006)

A Case of Primary Chylopericardium in Which Three-Dimensional Computed Tomography Scan with Lymphangiography Was Useful

(Department of Cardiovascular Surgery, Social Insurance Chukyo Hospital, Nagoya, Japan)

Noriyuki Kato	Hajime Sakurai	Tomonobu Abe
Hiroki Hasegawa	Sadanari Sawaki	Takahisa Sakurai
Junya Sugiura

A 36-year-old previously healthy woman with cardiomegaly on a routine chest X-ray was given a diagnosis of primary chylopericardium after pericardial puncture revealed milky effusion. Endoscopy-assisted ligation of the thoracic duct and creation of a pericardial window was performed. The operation was greatly facilitated by the preoperative three-dimensional CT scan with lymphangiography that precisely demonstrated the distribution of the thoracic duct and other lymphatic ducts.
　Jpn. J. Cardiovasc. Surg. 35: 246-250 (2006)

Surgical Treatment of Abdominal Aortic Aneurysm Accompanied by Bilateral Large Multicystic Kidneys

(Department of Cardiovascular Surgery and Department of Urology*, Kanazawa Medical University, Ishikawa, Japan)

Hiroo Shikata	Kimihiro Kurose	Takashi Kobata
Kenji Hida	Manabu Moriyama*	Nobuyo Morita*
Shigeru Sakamoto	Kouji Suzuki*	Junichi Matsubara

Abdominal aortic aneurysm and cystic kidneys are both common diseases that have been increasingly detected due to the development of medical screening instruments, such as computed tomography and ultrasonography. We occasionally intraoperatively encounter abdominal aortic aneurysms accompanying cystic renal lesions. However, there have been extremely few reports about abdominal aortic aneurysms complicated by cystic renal disease. Large renal cysts or polycystic kidneys are at risk of rupture or intraoperative hemorrhage, and can hinder the surgical treatment of abdominal aortic aneurysm. Therefore, there is a significant need for surgeons to be able to preoperatively determine the potential of an interruption of the procedure, for example, due to a cystic lesion. In this paper, we report a case of a 77-year-old man with abdominal aortic aneurysm who complained of abdominal fullness due to the presence of large cystic lesions in both kidneys. Preoperatively we aspirated 1,550ml percutaneously from bilateral renal cysts under ultrasonographic guidance, but did not instill sclerosing agents, such as ethanol. Three days after the percutaneous aspiration, surgical treatment of the abdominal aortic aneurysm（5.2cm in diameter), the left common iliac arterial aneurysm and the right common iliac arterial aneurysm（3.0 and 2.6cm in diameter）was performed through a median abdominal incision with a retroperitoneal approach. The arterial prosthesis used was a Y-shaped woven double velour vascular graft. The postoperative course was uneventful and the patient was discharged 14 days after the vascular reconstruction procedure. Our experience suggests that percutaneous aspiration of large renal cysts that might hinder the surgical procedure for abdominal aortic aneurysm is useful.
　Jpn. J. Cardiovasc. Surg. 35: 251-254 (2006)