Japanese Journal of Cardiovascular Surgery Vol.35, No.5

Validity of Emergency Thoracic Aortic Surgery in Octogenarians

(Department of Cardiovascular Surgery, Chiba Cardiovascular Center, Ichihara, Japan)

Masaki Yamamoto	Hirokazu Murayama	Hiroyuki Kito
Kozo Matsuo	Naoki Hayashida	Soichi Asano
Masao Hirano	Katsuhiko Tatsuno

Between January 1994 and October 2004, 87 patients underwent emergency thoracic aortic surgery. Of these, 11 patients were more than 80 years old (O-group) and 76 were less than 80 years old (Y-group). A total of 58 patients (6 in O-group and 52 in Y-group) were treated for acute type-A aortic dissection, 5 (0 in O-group and 5 in Y-group) for acute type-B aortic dissection and 21 (4 in O-group and 17 in Y-group) for the involved rupture of a thoracic aortic aneurysm. The operative procedures consisted of the replacement of either the ascending, or the ascending and transverse aorta in 71 patients (8 in O-group and 63 in Y-group), and the replacement of the distal descending aorta in 15 patients (3 in O-group and 12 in Y-group). The operative mortality rates were 27.2% (3 patients) and 19.7% (15 patients) in the O- and Y-groups, respectively, with no significant difference between the groups. The rate of early complications, including circulatory failure, respiratory failure and cerebral infarction, did not statistically differ between the 2 groups. The overall 2-year survival rates of the patients who survived the operation were 83.3% in the O-group and 95.1% in the Y-group. Moreorer, 75% of the patients (6 of 8) who survived the surgery regained normal activities of daily life after the surgery, at a level similar to before the surgery. The present data indicates that emergency thoracic aortic surgery can be justified in selected in octogenarian patients.
　Jpn. J. Cardiovasc. Surg. 35: 255-260 (2006)

A Case of Traumatic Aortic Dissection Associated with Multiple Trauma

(Division of Cardiovascular Surgery, Showa General Hospital, Kodaira, Japan and Saitama Medical School*, Saitama, Japan)

Masahiko Ozaki	Hiroshi Hojo	Kazuhiro Kochi
Yuji Yokote*	Shunei Kyo*

A 59-year-old woman with blunt multiple trauma was transferred to our emergency unit. A computed tomography revealed both an intimal flap of the descending aorta and cerebral bleeding. Immediate aortic surgery was considered, however full heparinized cardiopulmonary bypass (CPB) was not suitable because of acute brain hemorrhage. We performed surgery 55 days after the trauma. On operation 75% of the intima at the descending aorta was disrupted circumferentially. The descending aorta was replaced by a prosthetic graft under CPB. The postoperative course was uneventful and the patient has been well for 30 months after surgery. In treating aortic dissection associated with blunt trauma, emergency surgery should be performed immediately when possible, however there can be some limitations because of other acute organ injury. Accurate information concerning other injured organs, obtained by careful examination, may help an appropriate decision to be reached.
　Jpn. J. Cardiovasc. Surg. 35: 261-263 (2006)

A Case of Primary Cardiac Lymphoma with Complete Atrio-Ventricular Block and Superior Vena Cava Syndrome

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

Hiromichi Sonoda	Kunihiko Jouo	Masayoshi Umesue
Koji Matsuzaki	Kanzi Matsui

Primary cardiac malignant lymphoma (PCL), which is defined as an extra-nodal malignant lymphoma involving only the heart and/or pericardium, is extremely rare. Its prognosis is reported to be very poor because the PCL grows rapidly and frequently causes fatal heart failure or arrhythmias. We report a 65-year-old woman with PCL accompanied with superior vena cava (SVC) syndrome 6 weeks following a pacemaker implantation for complete atrio-ventricular block. She underwent a partial resection of the tumor to release the SVC syndrome and subsequent systemic chemotherapy. This combined therapy successfully induced complete remission, and improvement of the atrio-ventricular conduction disturbance was also observed.
　Jpn. J. Cardiovasc. Surg. 35: 264-267 (2006)

Off-Pump Coronary Artery Bypass Grafting through the Diaphragm Using the Splenic Artery for Inflow in a Redo Case with Chronic Renal Failure

(Department of Cardiovascular Surgery, Aomori Rosai Hospital, Hachinohe, Japan)

Mamoru Munakata	Hiroyuki Itaya	Yuichi Ono

Off-pump coronary artery bypass grafting (CABG) through the diaphragm is effective in redo cases who need right coronary revascularization with a patent graft. This is a rare report of this operation using the splenic artery for inflow. A 64-year-old man on chronic hemodialysis had undergone coronary artery bypass grafting (4 vessels) 9 years previously had chest pain and was transferred to our hospital with a diagnosis of acute myocardial infarction. Coronary arteriography revealed multiple stenoses of the right coronary artery with patent bypass grafts. The patient underwent emergency off-pump CABG through the diaphragm using a saphenous vein graft bridging from the splenic artery to the posterior descending branch and A-V node branch using the sequential method. The graft was patent in postoperative angiography and he was discharged on the 13th day after the operation, free of angina.
　Jpn. J. Cardiovasc. Surg. 35: 268-270 (2006)

A Case of Aortic Valve-Sparing Operation for Unruptured Aneurysm of Valsalva's Sinus

(Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan)

Chieri Kimura	Tatsuhiko Komiya	Nobushige Tamura
Genichi Sakaguchi	Taira Kobayashi	Hiromasa Nakamura

A 49-year-old woman was found to have unruptured Valsalva's sinus aneurysm. All of the sinuses were involved in the anuerysmal dilatation and the aortic valve was intact with no aortic insufficiency. Aortic root reconstruction surgery (root remodeling operation) was successfully performed and the histopathology of the aortic wall showed healed aortitis. Her postoperative course was uneventful. Valve-Sparing surgery can be one option, even in cases with aortitis.
　Jpn. J. Cardiovasc. Surg. 35: 271-274 (2006)

Aortoureteric Fistula after Total Cystectomy Complicated with Multidrug-Resistant Pseudomonas Infection

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

Kenji Matsuzaki	Norihiko Shiiya	Tomoyoshi Yamashita
Takashi Kunihara

A 77-year-old man, who had undergone total cystectomy, was transferred to our hospital because of repeated arterial bleeding from the left cutaneous urostomy on urostomy catheter exchange. Abdominal CT scan revealed infrarenal aortic and bilateral common iliac aneurysms. Multidrug-resistant Pseudomonas was detected from preoperative urine culture. A fistula between the left iliac artery and the left ureter was strongly suspected and an operation was performed. Aneurysmectomy and graft replacement with a bifurcated graft was conducted. Both limbs of the Y-graft were anastomosed to the right internal and external iliac artery. The left lower extremity was revascularized using femorofemoral bypass. After left nephrostomy, the graft was wrapped around with an omental flap. The postoperative course was uneventful, without infective complications.
　Jpn. J. Cardiovasc. Surg. 35: 275-277 (2006)

A Case of Aneurysm of the Deep Femoral Artery Treated by Transcatheter Embolization

(Department of Thoracic and Cardiovascular Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan)

Naoki Kida	Takashi Watanabe	Hiroomi Murayama
Takashi Yano	Keiji Ohhara	Atsukata Kobayashi

A 56-year-old man felt something abnormal in his right upper leg and 2 weeks later, sudden severe pain occurred. He was admitted to our department, on the suspicion of peripheral artery aneurysm. Arteriography showed a right deep femoral artery aneurysm. We successfully treated him with transcatheter embolization. Selective angiography of the deep femoral artery after the embolization disclosed complete occlusion of the aneurysm. We concluded that this minimally invasive treatment by transcatheter embolization for aneurysm of the deep femoral artery may be the first treatment of choice rather than operative resection.
　Jpn. J. Cardiovasc. Surg. 35: 278-280 (2006)

"Hybrid" Strategy for High-Risk Fontan Type Operation: Case Report of Pulmonary Atresia with Intact Ventricular Septum and Aortic Stenosis

(Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan)

Minori Tateishi	Masaaki Koide	Shinji Uchita
Kazumasa Watanabe

The Fontan type operation is currently considered to be a safe procedure. However, in some patients excluded from the indication for the Fontan type operation is contraindicated. A 12-year-old girl given a diagnosis of pulmonary atresia with intact ventricular septum was considered a high risk and was excluded form the indications of the Fontan procedure. She underwent balloon angioplasty for aortic stenosis (valvular) at the age of 2, and bidirectional Glenn anastomosis and aortic valve plasty at the age of 5. At the age of 7, she underwent cardiac catheterization. Although the Fontan procedure was contraindicated, her symptoms gradually progressed year by year, and desaturation caused a decrease in her exercise tolerance. At age 12, she underwent coil embolization of aortopulmonary collaterals and a fenestrated Fontan procedure. In order to keep the procedure as minimally invasive as possible, we performed intraoperative stenting of the peripheral pulmonary stenosis, and all manipulation of fenestrated extracardiac conduit Fontan procedures were performed in the beating heart with cardiopulmonary bypass. The postoperative course was uneventful. The oxygen saturation increased to 95%, and her exercise tolerance dramatically improved. Here we report some special techniques that hybrid operation and satisfactory results.
　Jpn. J. Cardiovasc. Surg. 35: 281-285 (2006)

Successful Surgical Treatment of a Ruptured Isolated Internal Iliac Artery Aneurysm

(Department of Cardiovascular Surgery, Sendai City Medical Center, Sendai Open Hospital, Sendai, Japan)

Seijiro Yoshida	Yoshimasa Moizumi

A 90-year-old man was admitted to the emergency room with acute right back pain. Immediate computed tomography (CT) scan demonstrated a large retroperitoneal hematoma and the presence of a ruptured 7-cm in diameter right internal iliac artery aneurysm. The patient subsequently developed rapid onset of hemorrhagic shock, which prompted an emergency operation. He made an uneventful recovery and was discharged on the 27th day after surgery without any problems. Isolated internal iliac artery aneurysms are rare but are dangerous and are associated with a high incidence of rupture and operative mortality. Repair of the aneurysms can be challenging, particularly in the face of rupture.
　Jpn. J. Cardiovasc. Surg. 35: 286-288 (2006)

Transaortic Cannulation for Balloon Pumping in a Patient with Angina and Abdominal Aortic Occlusion

(Department of Cardiovascular and Thoracic Surgery, Akashi Medical Center, Akashi, Japan)

Kazunori Yoshida	Satoshi Tobe	Masahiro Yamaguchi

A 64-year-old man with a history of abdominal aortic occlusion was admitted because of anterior chest pain. Angina pectoris with ischemic mitral regurgitation were diagnosed by transthoracic echocardiography and coronary artery angiography. He underwent coronary artery bypass grafting and mitral valve annuloplasty with a 26-mm Physio-ring. Because of difficulty in weaning from cardiopulmonary bypass, he required IABP support which was introduced via the ascending aorta. On the 2nd postoperative day, IABP was discontinued and the sternum was closed. His postoperative course thereafter was uneventful without any neurological complications. Postoperative echocardiogram showed good mitral valve function. He was discharged 16 days after surgery.
　Jpn. J. Cardiovasc. Surg. 35: 289-291 (2006)

A Case of Mycotic Aneurysm of the Pulmonary Artery with Pulmonary Artery Fistula following Pulmonary Artery Banding

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

Yoshihiro Ko	Kiyozo Morita	Yoko Matsumura
Katsushi Kinouchi	Ken Nakamura	Kazuhiro Hashimoto

A 9-month-old boy who had been given a diagnosis of double outlet right ventricle (DORV), partial anomalous pulmonary venous return (PAPVR), ventricular septal defect (VSD), pulmonary hypertension (PH) and polysplenia with azygos connection, underwent pulmonary artery banding at the age of 6 months. At 2 months after surgery, a chest computed tomogram revealed a main pulmonary artery aneurysm and a main pulmonary artery-right pulmonary artery fistula caused by bacterial endocarditis due to a methicillin-resistant Staphylococcus epidermidis. We performed pulmonary arterioplasty and re-pulmonary artery banding for acute aggravation of cardiac insufficiency and obtained good results. This is an extremely rare case that was treated infectious pulmonary artery aneurysm and fistula after pulmonary artery banding.
　Jpn. J. Cardiovasc. Surg. 35: 292-294 (2006)

Two Cases of Right Atrial Rupture due to Blunt Chest Injury in Teenaged Drivers after Motor Vehicle Accidents

(Department of Cardiovascular Surgery, Nagahama City Hospital, Nagahama, Japan, Department of Cardiovascular Surgery, Kumamoto Central Hospital*, Kumamoto, Japan and Department of Cardiovascular Surgery, Shizuoka General Hospital**, Shizuoka, Japan)

Masatsugu Hamaji	Satoshi Kono	Masanosuke Ishigami*
Akiyoshi Mikuriya	Mitsuru Kitano**	Mitsuhiko Matsuda

Cardiac injury following blunt chest trauma requires immediate transportation, correct diagnosis and early surgical treatment. We present 2 cases of rare cardiac rupture, right auricular laceration and multiple ruptures of vena cava, respectively. Case 1: An 18-year-old male driver was transported to a local hospital in a state of shock immediately after a traffic accident. Chest CT demonstrated cardiac tamponade. After temporary hemodynamic improvement by pericardiocentesis, he was referred to our hospital. Since his blood pressure decreased below the measurable threshold in the ICU, he was transferred to the OR after emergency subxiphoid pericardial drainage. On opening the pericardium after full sternotomy, the right atrial appendage laceration was found, about 1cm in length, and was sutured easily without cardiopulmonary bypass or any transfusion. Postoperative recovery was uneventful. Case 2: A 19-year-old male driver was directly transferred in an apneic shock state. Chest CT revealed cardiac tamponade. Full sternotomy was promptly carried out in the ICU after cardiopulmonary resuscitation (CPR) and subxiphoid pericardial drainage. Caval injury was found, 2cm in length, in both the superior vena cava (SVC) and intrapericardial inferior vena cava (IVC). His circulatory state was restored after the repair of these caval injuries without cardiopulmonary bypass; however, he died from severe brain damage postoperatively. In summary, blunt rupture of the right heart could be saved by prompt transport with airway assist, pericardial drainage, and proper surgery.
　Jpn. J. Cardiovasc. Surg. 35: 295-298 (2006)

A Case of Neuroleptic Malignant Syndrome following Open Heart Surgery

(Department of Cardiovascular Surgery, Saku Central Hospital, Saku, Japan)

Gen Shinohara	Kazuaki Shiratori

A 57-year-old man who underwent aortic root replacement developed continued to have high-grade fever and rhabdomyolysis after administration of haloperidol on the 10th postoperative day, resulted in deterioration of respiratory and hemodynamic status. We established a diagnosis of neuroleptic malignant syndrome (NMS) incomplete type with difficulty after examination by a psychiatrist, and started administration of dantrolen on postoperative day 17. The serum level of CK rapidly decreased. Because NMS causes severe worsening of general status, early diagnosis and immediate treatment is important particularly after cardiac surgery. Care should be paid to the recognition of causative drugs and status, and symptoms of the early stag, such as muscular rigidity, psychiatric symptoms. It is necessary to investigate medical treatments immediately together with a psychiatrist or neurologist. On the other hand, NMS after heart valve replacements should be distinguished from prosthetic valve endocarditis, and the type of fever and inflammatory reaction can help in differential diagnosis.
　Jpn. J. Cardiovasc. Surg. 35: 299-303 (2006)

A Case of Open Stent Grafting for Type B Acute Aortic Dissection Complicated with Abdominal Angina

(Department of Cardiovascular Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan)

Norimitsu Shimada	Naomichi Uchida	Hidenori Shibamura
Hiroshi Iwako	Masamichi Ozawa

Acute aortic dissection is a formidable disease because of complications such as rupture or visceral ischemia. Early diagnosis of these conditions is essential. The patient was a 40-year-old woman with acute type B aortic dissection, suspected to have Marfan syndrome. We first treated her with medical therapy, but 5 days later she suffered from repeated abdominal angina. This was thought to be probably predictive of malperfusion, so we decided to perform an operation. We maintained an elevated blood pressure (about 140mmHg), used heparin and Prostaglandin E1 for the prevention of angina, until total aortic arch replacement and open stent grafting was performed. She has been doing well since.
　Jpn. J. Cardiovasc. Surg. 35: 304-307 (2006)