Japanese Journal of Cardiovascular Surgery Vol.35, No.6

Involvement of Sympathetic Activity in the Onset of Atrial Fibrillation following Cardiac Surgery

(Division of Cardiovascular Surgery, Kamo Hospital, Toyota, Japan and Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine*, Nagoya, Japan）

Takeru Shimomura	Akihiko Usui*	Yuichi Ueda*

Although atrial fibrillation is a complication frequently encountered after cardiac surgery in routine practice, no effective measure is available to prevent its onset, and surgeons often have great difficulties in managing their patients with this condition. On suspicion of the involvement of increased sympathetic activity in the onset, the pre-onset status of 57 patients was examined. The patients were supposedly at low risk of developing atrial fibrillation after cardiac surgery. Additionally, plasma concentrations and 24-hour cumulative urinary excretion of norepinephrine, a biochemical indicator of sympathetic activity, were measured before surgery and on days 3 and 7 of disease. As a result, a group of patients with atrial fibrillation were found to have higher pre-onset heart rates and significantly increased plasma norepinephrine concentrations and 24-hour cumulative urinary norepinephrine excretion compared to controls. Hence, increased sympathetic activity is considered to play a major role in the onset of atrial fibrillation following cardiac surgery.
　Jpn. J. Cardiovasc. Surg. 35: 309-314 (2006)

Aortic Valve Replacement for Severe Aortic Stenosis with Severe Left Ventricular Dysfunction

(Thoracic and Cardiovascular Surgery, Hepato-Biliary-Pancreatic Surgery, University of Kagoshima, Kagoshima, Japan)

Akihiro Higashi	Yoshifumi Iguro	Tetsuya Ueno
Hiromu Terai	Hiroyuki Yamamoto	Masahiro Ueno
Takayuki Ueno	Ryuzo Sakata

There is disagreement regarding the indications of surgery for cases of severe aortic stenosis (AS) with a decrease in left ventricular ejection fraction (EF) and a low aortic pressure gradient (PG), since there is a high perioperative risk associated with this condition. Hence, we investigated the surgical outcome of AS cases with impaired left ventricular function. Our department performed 144 aortic valve replacements (AVRs) for cases of AS and AS-dominant mild regurgitation (ASr) between January 2000 and September 2005. Among these cases, 9 patients had an EF under 35%, and these patients were selected as subjects and compared with a control group with an EF of more than 35%. Patients with accompanying coronary artery diseases that required treatment were excluded to avoid confounding effects on cardiac function. The mean age of the 9 subjects (4men and 5 women) was 67.8±10.8years old, with a range from 53 to 80 years old, and the subjects had the following mean background data: EF, 34.4±0.5%; left ventricular end-diastolic dimension (LVDd), 57.3±5.8mm; left ventricular end-systolic dimension (LVDs), 49.3±5.7mm; interventricular septum thickness (IVSth), 11.9±1.9mm; and left ventricular posterior wall thickness (LVPWth), 11.1±2.6mm. Characteristics such as left ventricular dilatation and thinning of the left ventricle myocardium were noted in these data. The cases were classified as severe AS because the mean aortic valve area (AVA) was 0.58±0.2cm2, but the peak aortic pressure gradient (peak PG) (65.2±32.7mmHg) in the 9 subjects was lower than that of the control group (97.0±65.2mmHg). All 9 subjects underwent aortic valve replacements (AVRs), with simultaneous mitral annuloplasty (MAP) in 3 cases, mitral valve replacement (MVR) in 1 case and performance of a Maze procedure in 1 case. No deaths occurred while the patients were in hospital. Postoperative complications included 2 cases of transient atrial fibrillation and 1 case of postoperative bleeding requiring rethoracotomy for hemostasis. The EF in the late postoperative period showed improvement in 8 cases and was unchanged in the remaining case; the mean postoperative EF was 56.9% for the 9 subjects. All cases were rated as improved based on the NYHA classification of cardiac performance, and the significant improvement in EF in 8 of the 9 cases suggests that surgery is safe and can improve prognosis for patients with advanced AS with myocardium thinning and decreased EF.
　Jpn. J. Cardiovasc. Surg. 35: 315-318 (2006)

Clinical Comparison of a New Non-Sealed Woven Dacron Graft and Sealed Woven Dacron Grafts

(Department of Cardiovascular Surgery, Kinki University, School of Medicine, Osakasayama, Japan)

Takuma Satsu	Takehiro Inoue	Takako Nishino
Kousuke Fujii	Junko Okamoto	Ken Okamoto
Terufumi Matsumoto	Susumu Nakamoto	Hitoshi Kitayama
Toshihiko Saga

The UBE woven 150cc WYK graft is a non-sealed graft that became available commercially in January 2005, and does not need to be preclotted before implantation. Subjects in this study comprised 50 patients with abdominal aortic aneurysms or common iliac arterial aneurysms, who received prosthetic Y grafts in our institution. Subjects were divided into 2 groups: the U group (n＝26), with implantation of the UBE graft, and the I group (n＝24) who received implantation of an INTERGARD^™ woven Y graft. Intraoperative bleeding, inflammatory response and duration of postoperative hospitalization were evaluated in each group. Significant differences were noted between C-reactive protein levels, frequency of recurrence of fever and duration of postoperative hospitalization. No differences were noted between intraoperative bleeding and time. The UBE woven 150cc WYK graft, compared with the INTERGARD^™ woven Y graft, required no extra time for implantation and appeared to offer advantages such reduced immunoreaction after surgery. However, follow-up for sufficient late-phase evaluation of the grafts is required.
　Jpn. J. Cardiovasc. Surg. 35: 319-323 (2006)

A Case of Infrarenal Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia

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

Hiroyuki Kurosawa	Hirono Satokawa	Yoichi Sato
Shinya Takase	Koki Takahashi	Yukitoki Misawa
Yuki Seto	Eitoshi Tsuboi	Kenichi Muramatsu
Hitoshi Yokoyama

Spinal cord ischemia is a very rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms. A 65-year-old man who had a history of CABG (LITA-LAD, LITA-Y composite RA-OM) underwent resection of an abdominal aortic aneurysm. Postoperatively, he developed paraplegia and hypoesthesia with associated fecal incontinence. Reduction of collateral flows of patent lumbar arteries probably caused serious ischemia of the spinal cord. A standard infra-renal abdominal aorta surgery still has the risk of postoperative paraplegia, which should be incorporated in the preoperative informed consent.
　Jpn. J. Cardiovasc. Surg. 35: 324-327 (2006)

Sutureless Repair of Pulmonary Venous Obstruction after Repair of Total Anomalous Pulmonary Venous Connection (1a＋2a）

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

Katsushi Kinouchi	Kiyozo Morita	Kazuhiro Hashimoto
Koji Nomura	Yoshimasa Uno	Youkou Matsumura
Ken Nakamura	Takayuki Abe	Hiroshi Kagawa
Tooru Sakuma*

Pulmonary venous obstruction (PVO) after repair of total anomalous pulmonary venous connection remains a significant problem. Once it occurs, it not infrequently recurs. A 14-month-old boy with recurrent pulmonary venous obstruction after repair of mixed type total anomalous pulmonary venous connection was successfully treated by the method of sutureless in situ pericardial repair and anastomosis of the left pulmonary vein to the left atrial appendage. His postoperative course was uneventful. Cardiac catheterization at 2 years and 9 months after the re-redo operation showed successful relief of PVO with marked reduction of pulmonary hypertension. In addition, multidetector computed tomography (MDCT) performed 3 years and 1 month after the operation showed no pulmonary vein obstruction.
　Jpn. J. Cardiovasc. Surg. 35: 328-332 (2006)

Aneurysm of the Subclavian Artery and Aneurysm of the Cerebral Artery in Association with Congenital Absence of Ipsilateral Internal Carotid Artery

(Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan)

Fuyuki Asami	Takashi Wakabayashi	Osamu Namura
Masakazu Sogawa	Jun-ichi Hayashi

A 56-year-old man had aneurysms of the right subclavian artery and cerebral artery in association with congenital absence of the right internal carotid artery. The aneurysm of the subclavian artery was successfully surgically repaired through a partial sternotomy. Congenital absence of the internal carotid artery is rare vascular anomaly. This anomaly contributes to the occurrence of intracranial aneurysms. However, aneurysm of subclavian artery associated with congenital absence of the internal artery is very rare. This is the 3rd case reported in the literature.
　Jpn. J. Cardiovasc. Surg. 35: 333-335 (2006)

A Case of Off-Pump Coronary Artery Bypass Grafting in a Patient with Liver Cirrhosis, Advanced Thrombocytopenia and Coronary Artery Aneurysm

(Department of Cardiovascular Surgery, Misato Junshin General Hospital, Misato, Japan and Division of Cardiovascular Surgery, Department of Surgery (Omori), School of Medicine, Toho University*, Tokyo, Japan)

Muneyasu Kawasaki	Yoshinori Watanabe*	Noritsugu Shiono*
Satoshi Hamada*	Hiroshi Masuhara	Katsushi Niitsu
Nobuya Koyama*

A 67-year-old man presented complaining of unstable angina. Coronary angiography revealed 50% stenosis of the left main trunk of the left coronary artery and a coronary artery aneurysm in the left anterior descending artery (LAD) #6. Furthermore, significant stenosis was noted in the peripheral LAD #7 and #9. The patient had hepatitis C, probably due to an earlier transfusion, and was suffering from liver cirrhosis (Child-Pugh classification grade A) and advanced thrombocytopenia. We anastomosed the saphenous vein graft (SVG) to the LAD and diagonal branch by off-pump coronary artery bypass grafting; we did not treat the aneurysm. There were no postoperative complications and the patient's progress was good. On postoperative coronary angiography, the aneurysm was occluded and the patency of the SVG was satisfactory.
　Jpn. J. Cardiovasc. Surg. 35: 336-339 (2006)

A Case of Papillary Fibroelastoma of the Right Atrium with Pulmonary Embolism

(Department of Cardiovascular Surgery, Federation of National Public Service Personnel Mutual Aid Association Shinbeppu Hospital, Beppu, Japan)

Tatsunori Kimura	Toshihide Yoshimatsu

A 78-year-old man experienced transient palpitations. Echocardiography disclosed a mobile tumor measuring 8mm in diameter in the right atrium. Although the symptom was transient, surgical resection with cardiopulmonary bypass was performed because of the detection of multiple perfusion defects on lung perfusion scintigraphy. The tumor was found to be papillary fibroelastoma. Papillary fibroelastoma is a benign endocardiac tumor less frequent than myxoma and cardiac lipoma, and commonly arising from a heart valve. Papillary fibroelastoma arising from the right atrium is rare. The postoperative course was uneventful, and the mass has not recurred during one year of follow-up.
　Jpn. J. Cardiovasc. Surg. 35: 340-342 (2006)

A Successfully Operated Case of Traumatic Aortic Disruption with Multisystem Trauma

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

Hiroyuki Watanabe	Kayoko Kobayashi	Takuto Maruyama

A 63-year-old man suffered from multisystem trauma including pelvic bone fracture and lung contusion caused by a traffic accident. Chest CT revealed mediastinum and periaortic hematoma. Because of hemorrhagic complications, a emergency operation was avoided, and conservative therapy was decided on. Though his blood pressure was controlled strictly, re-bleeding appeared. An urgent operation was performed 4 days after the injury. Under partial cardiopulmonary bypass, the aortic isthmus disruption was resected and replaced with an artificial graft. The postoperative course was uneventful. In cases of traumatic aortic disruption with multisystem trauma, the delayed operation is more common than urgent operation. However, there is always the possibility of rupture. It is extremely important to appropriately judge the timing of the operation.
　Jpn. J. Cardiovasc. Surg. 35: 343-346 (2006)

A Rare Case of Abdominal and Thoracic Aortic Aneurysm Complicated with Buerger's Disease

(Department of Surgery and Cardiovascular Surgery, Nemuro City Hospital, Nemuro, Japan and Department of Emergency Medicine, Asahikawa Medical College*, Asahikawa, Japan)

Satoshi Hayashi	Hiroki Yoshida	Hirokatsu Sugimoto
Yuka Kajiura	Kazutomo Goh*

We report a rare case of a 73-year-old man with abdominal and thoracic aortic aneurysms complicated with Buerger's disease. He complained of abdominal pain, nausea and an abdominal pulsatile mass. Computed tomography and angiography revealed an abdominal aortic aneurysm (58mm in diameter) and a thoracic aortic aneurysm (47mm in diameter). Y graft replacement was performed for abdominal aortic aneurysm. The size of the thoracic aortic aneurysm increased from 47mm to 60mm in 3 years, and hoarseness appeared. We then performed graft replacement of the thoracic aorta. In cases of Buerger's disease, we have to consider perfusion of the extremities when we need extracorporeal circulation, and we must shorten ischemic interval.
　Jpn. J. Cardiovasc. Surg. 35: 347-350 (2006)

Ruptured Coronary Artery Aneurysm with a Fistulous Communication

(Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan)

Akira Yamazaki	Touitsu Hirayama	Hiroyasu Misumi
Yasuhiro Shimokawa	Hideyuki Uesugi	Ichiro Ideta
Masamitsu Murata

A 68-year-old woman was referred to our hospital with arrhythmia and cardiomegaly. She lost consciousness in the waiting room. After urgent hospitalization, cardiac ultrasonography showed cardiac tamponade, and urgent pericardial drainage was performed. A ruptured coronary aneurysm with a fistulous communication was diagnosed by CT scan and coronary angiography. Under extracorporeal circulation, ligation of the unusual coronary vessels and resection of the aneurysm were performed. The postoperative course was uneventful and she was discharged on the 25th postoperative day. No ischemic signs were observed on treadmill test at one year after surgery. Most congenital coronary aneurysms are asymptomatic; however, once rupture occurs, it is important to diagnose this condition rapidly and treat surgically.
　Jpn. J. Cardiovasc. Surg. 35: 351-353 (2006)

A Case of Cholesterol Crystal Embolism after Coronary Artery Bypass Grafting

(Department of Cardiovascular Surgery, Yamagata Saisei Hospital, Yamagata, Japan)

Yoko Sotoda		Shigeki Hirooka
Hiroyuki Orita

We report a case of cholesterol crystal embolism (CCE) after coronary bypass surgery. A 65-year-old man with unstable angina and abdominal aortic aneurysm (AAA) underwent coronary artery bypass grafting (CABG). Coronary angiography (CAG) was performed at 30 days after surgery. Two weeks after the CAG, plantar cyanosis of both feet was observed and a renal dysfunction developed. A skin biopsy of the cyanotic lesion demonstrated characteristic cholesterol clefts in small submucosal arteries. Methylprednisolone (MPSL) and prostaglandin E1 (PGE1) were given for 3 days and 2 weeks, respectively. The patient's condition improved remarkably. Two months after the CAG, resection of AAA was performed and the postoperative course was uneventful. Diagnosis of CCE is difficult and its prognosis still remains poor. Therefore, we should keep this unusual complication in mind
　Jpn. J. Cardiovasc. Surg. 35: 354-357 (2006)

Two Cases of Infected Abdominal Aortic Aneurysm

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

Masatsugu Hamaji	Satoshi Kono	Mitsuru Kitano*
Mitsuhiko Matsuda

We describe successful resection and anatomical revascularization in 2 men aged 75- and 50 who suffered from prolonged systemic infection. Blood culture was positive in both cases, Klebsiella pneumoniae and Staphylococcus aureus (MSSA), respectively. Case 1 was misdiagnosed as acute appendicitis and underwent laparotomy. Postoperative CT revealed leaking aneurysm. Case 2 was diagnosed correctly on screening CT. Bacterial culture of all surgical specimens proved negative. The postoperative course was fortunately uneventful. The early and accurate diagnosis of infected aneurysm is important to establish surgical strategy. Timing of surgical intervention is still difficult to determine for minimizing the risk of graft infection.
　Jpn. J. Cardiovasc. Surg. 35: 358-362 (2006)

Valve Replacement for Infective Endocarditis following Vertebral Osteomyelitis: Report of Two Cases

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

Kiyoshi Tamura	Dai Tasaki	Toshizumi Shirai
Nagahisa Oshima

Vertebral osteomyelitis (VO) is a relatively rare, but lethal, complication of infective endocarditis (IE). We report two cases who had been given a diagnosis of IE during conservative therapy for VO. A 60-year-old and a 52-year-old men each suffered onset of severe back pain. Magnetic resonance imaging demonstrated osteomyelitis in the lumbar spine. IE was revealed from congestive heart failure and persistent fever, as an unusual complication of VO. A series of echocardiograms demonstrated the progression of valvular lesions and vegetation, despite treatment with antibiotics. We therefore performed surgery. One underwent aortic and mitral valve replacement, and the other underwent aortic valve replacement. VO was treated with long-term antibiotics and good responses were achieved in both patients. The possibility of VO in the lumbar spine should be considered in patients with IE complaining of severe back pain. Appropriate antibiotic therapy over a prolonged period is recommended.
　Jpn. J. Cardiovasc. Surg. 35: 363-366 (2006)

A Patient with an Aortic-Root Pseudoaneurysm in Whom Intraaortic Balloon Pumping Improved Cardiogenic Shocka

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

Hiroyuki Adachi	Kiyotaka Imoto	Shinichi Suzuki
Keiji Uchida	Motohiko Gouda	Toshiki Hatsune
Makoto Okiyama	Takayuki Kosuge*	Hiroshi Toyoda*
Yoshinori Takanashi**

A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.
　Jpn. J. Cardiovasc. Surg. 35: 367-370 (2006)