Japanese Journal of Cardiovascular Surgery Vol.36, No.1

Originals

  • Valve Replacement in Hemodialysis Patients in Japan 　　M. Aoki, et al.…1
    Valve Replacement in Hemodialysis Patients in Japan

    (Department of Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan and Department of Cardiovascular Surgery, Nagoya Kyouritsu Hospital*, Nagoya, Japan)
    Masakazu Aoki Yoshiyuki Nishimura Hiroshi Baba
    Masanori Hashimoto Yasuhide Ohkawa Yoshitaka Kumada*
    A retrospective review was performed on 43 patients on hemodialysis undergoing valve surgery between May 1999 and August 2004. Ages ranged from 36 to 80 years (mean, 63.8 years). Twenty aortic, 9 mitral, 8 aortic and mitral and 6 valvuloplasties were performed. Twenty-three aortic mechanical valves, 5 aortic bioprosthetic valves, 13 mitral mechanical valves and 4 mitral bioprosthetic valves were implanted. Twenty-five of the 28 aortic valve replacement were hypoplasia of the aortic valve ring. There were 3 hospital deaths (heart failure, pneumonia and sepsis). There were 10 late deaths (2 heart failure, 2 pneumonia, wound infection, cerebral infarction, 2 cancer, arteriosclerosis obliterans and unknown death). Survival at 1,3 and 5 years was 81%, 74% and 47%. There were three documented major bleedings or thromboembolisms in the 29 patients with mechanical valves (10%) and none in the 9 patients with bioprosthetic valves (0% no significance). Three reoperations were performed for premature degeneration of bioprosthetic valve (19, 24 and 50 months) due to accelerated calcification. These results demonstrate that the prosthetic valve-related major bleedings and strokes in hemodialysis patients are similar for both mechanical and bioprosthetic valves, and that bioprosthetic valves will undergo premature degeneration. Therefore, preference should be given to mechanical valve prostheses in hemodialysis patients.
    　Jpn. J. Cardiovasc. Surg. 36: 1-7 (2007)

Case Reports

  • A Successful Case of Axillo-Axillary Crossover Grafting in a Patient with Coronary Subclavian Steal Syndrome Developing Cardiogenic Shock 　　H. Kobayashi, et al.…8
    A Successful Case of Axillo-Axillary Crossover Grafting in a Patient with Coronary Subclavian Steal Syndrome Developing Cardiogenic Shock

    (Department of Cardiovascular Surgery, Chugoku Rosai Hospital, Kure, Japan)
    Hironori Kobayashi Masafumi Sueshiro Keijiro Katayama
    Retrograde flow of the left internal thoracic artery (LITA) secondary to proximal left subclavian artery occlusion or severe stenosis in patients who underwent coronary artery bypass grafting (CABG) using a LITA graft can result in myocardial ischemia. This phenomenon is termed as "coronary subclavian steal syndrome (CSSS)". We report on a successful case of axillo-axillary crossover grafting in a patient with CSSS who suffered cardiogenic shock. A 70-year-old woman had undergone CABG using a LITA graft 10 years previously. The patient developed cardiogenic shock. Emergency angiography revealed retrograde flow of the LITA from the left coronary artery and occlusion of the proximal left subclavian artery. We performed axillo-axillary crossover grafting because anginal pains recurred due to CSSS. The pains disappeared after the operation. This technique appears to be useful in patients with CSSS who suffer cardiogenic shock.
    　Jpn. J. Cardiovasc. Surg. 36: 8-11 (2007)
  • Papillary Fibroelastoma Complicated with Ischemic Heart Disease and Arteriosclerosis Obliterans Treated Successfully by Surgery 　　T. Shimamoto, et al.…12
    Papillary Fibroelastoma Complicated with Ischemic Heart Disease and Arteriosclerosis Obliterans Treated Successfully by Surgery

    (Department of Cardiovascular Surgery, Kyoto University Hospital, Kyoto, Japan, Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital*, Kyoto, Japan, Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital**, Kyoto, Japan and Department of Cardiovascular Surgery, Nagahama Municipal Hospital***, Nagahama, Japan)
    Takeshi Shimamoto Toshifumi Takeuchi* Hiroyuki Nakajima**
    Akiyoshi Mikuriya*** Motoyuki Oda
    A 67-year-old man had been followed up in our cardiology clinic for ischemic foot, and routine echocardiography revealed an 8×9mm highly echogenic mass on the mitral posterior leaflet. Because of the high thromboembolic risk, open-heart surgery was scheduled for surgical treatment of the tumor. His preoperative coronary angiogram showed 3 vessel disease. Coronary artery bypass grafting and tumor removal were performed consequently. His postoperative course was uneventful and the lesion was pathologically diagnosed a papillary fibroelastoma. No recurrence has occurred one year after the operation. Surgical treatment of cardiac tumors is mandatory for preventing embolism regardless of the size and location. Most of the tumors on cardiac valves are papillary fibroelastomas and recurrence of this tumor has not been reported so far. When the tumor is attached to a mitral leafet, simple tumor resection, with or without mitral valve repair, is justified instead of performing mitral replacement with en bloc resection of tumors and the entire leaflets.
    　Jpn. J. Cardiovasc. Surg. 36: 12-14 (2007)
  • Replacement of the Aortic Root and Ascending Aorta for Acute Aortic Dissection in a Patient with Liver Cirrhosis (Child-Pugh Class B) and Hepatic Cell Carcinoma 　　 K. Nakamura, et al.…15
    Replacement of the Aortic Root and Ascending Aorta for Acute Aortic Dissection in a Patient with Liver Cirrhosis (Child-Pugh Class B) and Hepatic Cell Carcinoma

    (Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Matsudo, Japan)
    Koki Nakamura Mikiko Murakami Tomohiro Asai
    Yosuke Saito Hiroki Yamaguchi
    A 62-year-old man was referred to us because of acute aortic dissection (Stanford type A). He had had liver cirrhosis (Child-Pugh class B) and hepatic cell carcinoma in the left lateral lobe, which had been resected 3 years ago. On admission he was drowsy and was in shock. CT showed dissection from the ascending aorta to the abdominal aorta. Echocardiography revealed severe aortic regurgitation. An emergency operation was indicated although it was a very high risk procedure. Under cardiopulmonary bypass with moderate hypothermia, the aortic root was replaced with a Freestyle valve (23mm). Then the ascending aorta was replaced with a woven Dacron graft (28mm) under cardiac arrest and isolated cerebral perfusion. Postoperatively, he had cardiac tamponade and cerebral infarction (perhaps due to the preoperative events). However, he was successfully discharged on the 34th postoperative day.
    　Jpn. J. Cardiovasc. Surg. 36: 15-18 (2007)
  • Mitral Valve Plasty in the Active Phase of Infective Endocarditis with Intracerebral Mycotic Aneurysms and Abscesses in the Brain and Lower Limb 　　H. Kagawa, et al.…19
    Mitral Valve Plasty in the Active Phase of Infective Endocarditis with Intracerebral Mycotic Aneurysms and Abscesses in the Brain and Lower Limb

    (Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan)
    Hiroshi Kagawa Kazuhiro Hashimoto Yoshimasa Sakamoto
    Hiroshi Okuyama Shinichi Ishii Shingo Taguchi
    A 38-year-old woman was referred to our hospital for treatment of infective endocarditis associated with abscesses in the brain and the left lower limb. A causative organism had not been detected by serial blood cultures. Preoperative brain CT revealed mycotic aneurysms and echocardiography showed a mobile vegetation (8mm in size) on the anterior leaflet of the mitral valve. We performed resection of the vegetation together with a small triangle of the anterior leaflet, after which the margins of the defect were approximated. Then bilateral Kay procedures and reinforcement with autologous pericardium were done to obtain proper coaptation. The patient's fever, left lower limb pain, and intracerebral mycotic aneurysms resolved after surgery. The brain abscess also became smaller. Mitral valve plasty should sometimes be considered in the active phase of endocarditis, even in patients with cerebral complications and without congestive heart failure.
    　Jpn. J. Cardiovasc. Surg. 36: 19-22 (2007)
  • A Case of Two-Stage Operation for Distal Arch Aortic Aneurysm with Occluded Right Middle Cerebral Artery 　　K. Gan, et al.…23
    A Case of Two-Stage Operation for Distal Arch Aortic Aneurysm with Occluded Right Middle Cerebral Artery

    (Division of Cardiovascular Surgery, Miki City Hospital, Miki, Japan)
    Kunio Gan Tatsurou Asada Takashi Azami
    Hiroya Minami
    A 68-year-old woman with distal arch aortic aneurysm was admitted. Preoperative magnetic resonance angiography revealed occlusion of the right middle cerebral artery. Single photon emission computed tomography showed decreased cerebral blood flow at rest and decreased reactivity to acetazolamide in the right temporal lobe. At first, a superficial temporal artery to middle cerebral artery anastomosis was made by neurosurgeons. Improvement of both the cerebral blood flow and the reactivity to acetazolamide was confirmed by single photon emission computed tomography 18 days after the operation. Twenty-two days after the operation, a total arch replacement was performed. The postoperative course was uneventful without any neurological complication.
    　Jpn. J. Cardiovasc. Surg. 36: 23-27 (2007)
  • Reconstruction of Intercostal Arteries by Posterior Wall Plasty of the Thoracoabdominal Aortic Aneurysm 　　O. Sogabe and T. Ohya…28
    Reconstruction of Intercostal Arteries by Posterior Wall Plasty of the Thoracoabdominal Aortic Aneurysm

    (Department of Cardiovascular Surgery, Mitoyo General Hospital, Kanonji, Japan)
    Osanori Sogabe Takashi Ohya
    Spinal cord ischemia after surgery of thoracoabdominal aortic aneurysm is still one of the serious complications encountered. We adopted a surgical technique with reconstruction of intercostal arteries together in 3cases in order to prevent intraoperative spinal cord ischemia. The posterior wall of the aorta, including the intercostal arteries, was trimmed and seamed, then anastomosed to the branched graft to the stem graft under deep hypothermia. This technique is simply performed with a running suture and enabled reconstruction of the intercostal arteries together below the fourth intercostal artery. Postoperative complications due to spinal cord ischemia or aneurysmal change of the reconstructed aorta have not appeared in the 4 years since operation.
    　Jpn. J. Cardiovasc. Surg. 36: 28-32 (2007)
  • A Case of Arch Anomaly with Right Aortic Arch and Pulmonary Artery Sling in Conjunction with Persistent Left Fifth Aortic Arch 　　J. Iwase, et al.…33
    A Case of Arch Anomaly with Right Aortic Arch and Pulmonary Artery Sling in Conjunction with Persistent Left Fifth Aortic Arch

    (Department of Cardiovascular Surgery, Aichi Children's Health and Medical Center, Obu, Japan and Department of Surgery, Emergency Medicine, Ichinomiya-West Hospital*, Ichinomiya, Japan)
    Jinichi Iwase* Masanobu Maeda Tomohiko Ukai
    Shigeru Sasaki
    Persistent fifth aortic arch has been thought to be rare but often relevant to systemic circulation, however when it connects to the pulmonary artery (PA) in pulmonary atresia, it may be the sole arterial supply to the lung. This report describes a case of rare arch anomaly including right aortic arch (RAA), PA sling in conjunction with persistent left fifth aortic arch (PLFAA) and left subclavian artery arising from the left fourth arch. The tetralogy of Fallot, pulmonary atresia, and total anomalous of pulmonary venous connection (cardiac) were also diagnosed. A neonate was referred to our hospital for surgical treatment of cardiac and extracardiac anomalies. Persistent fifth aortic arch connecting with pulmonary artery was initially thought to be patent ductus arteriosus (PDA), so prostaglandin E1 administration was commenced. He underwent emergency colostomy for anal atresia. Subepiglottic tracheal stenosis was diagnosed at initiation of anesthesia. At age 1-month-old, he required systemic to pulmonary shunt and reimplantation of left pulmonary artery through a median sternotomy using extracorporeal circulation. At the operation the PDA was divided and oversewn, and the wall structure was the same as that of a normal artery. The left pulmonary artery behind trachea was dissected and we then cut away and reimplanted to pulmonary trunk. Tracheostomy was performed at the age of two months. With the technical development of diagnostic imaging, the morphological features of arch anomaly were clearly demonstrated, but some understanding of embryological aspects are still required for diagnosis.
    　Jpn. J. Cardiovasc. Surg. 36: 33-36 (2007)
  • Total Aortic Arch Replacement for Ruptured Aortic Arch Aneurysm in a 92-Year-Old Woman 　　N. Shigemoto, et al.…37
    Total Aortic Arch Replacement for Ruptured Aortic Arch Aneurysm in a 92-Year-Old Woman

    (Department of Cardiovascular Surgery, Hiroshima General Hospital, Hatsukaichi, Japan)
    Norifumi Shigemoto Tatsuya Nakao Yasushi Kawaue
    Shingo Mochizuki
    We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.
    　Jpn. J. Cardiovasc. Surg. 36: 37-40 (2007)
  • Successful Treatment of a Chronic Pulmonary Thromboembolism Associated with Right Atrial Thrombus, Atrial Fibrillation and Tricuspid Insufficiency 　　H. Iida, et al.…41
    Successful Treatment of a Chronic Pulmonary Thromboembolism Associated with Right Atrial Thrombus, Atrial Fibrillation and Tricuspid Insufficiency

    (Department of Cardiovascular Surgery, Kimitsu Central Hospital, Kisarazu, Japan, National Hospital Organization Chiba Medical Center*, Chiba, Japan and Labour Health and Welfare Organization Kashima Hospital**, Kamisu, Japan)
    Hiroshi Iida Yoshio Sudo Hideo Ukita
    Masahisa Masuda* Nobuyuki Nakajima**
    We describe an unusual case of a chronic pulmonary thromboembolism with right atrial thrombus. A 56-year-old man suffering from chronic pulmonary thromboembolism for 5 years complained of increasing dyspnea. Computed tomography revealed massive emboli in bilateral pulmonary arteries and a thrombus in the right atrium. Massive tricuspid regurgitation and atrial fibrillation were also recognized. We performed pulmonary thromboendarterectomy using a Jamieson rigid long miniature sucker with a rounded tip and our original flexible sucker under deep hypothermic circulatory arrest. Right atrial thrombectomy, tricuspid annuloplasty and a Maze procedure were also performed during the cooling, recirculating, and warming period. His postoperative cause was uneventful, and he was able to return to an ordinary lifestyle without acquiring oxygen inhalation. Tricuspid annuloplasty and Maze operation during pulmonary thromboendarterectomy contributed to the maintenance of stable homodynamics during and after surgery.
    　Jpn. J. Cardiovasc. Surg. 36: 41-44 (2007)
  • A Case of Aortic Valve Rereplacement due to Complications of Autoimmune Hemolytic Anemia 　　H. Suzuki, et al.…45
    A Case of Aortic Valve Rereplacement due to Complications of Autoimmune Hemolytic Anemia

    (The Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Japan)
    Hitoshi Suzuki Hideki Ito Keizo Tanaka
    Shinji Kanemitsu Jin Tanaka Yoshihiko Kinoshita
    A 64-year-old man who underwent aortic valve replacement with a 25 mm Bjork-Shiley valve in 1993 began to have severe anemia and required repeated transfusions by November 2003. Doppler echocardiography showed only mild aortic regurgitation, but revealed turbulent flow around the mechanical valve. Autoimmune hemolytic anemia (AIHA) was diagnosed and he was treated with prednisolone (PSL) starting May 2004. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent rereplacement of the aortic valve with a 25-mm Freestyle valve. His hemolysis and general condition immediately improved. This case suggests the possibility that mild regurgitant jet and turbulent jet stress can cause severe hemolysis when AIHA develops.
    　Jpn. J. Cardiovasc. Surg. 36: 45-47 (2007)
  • A Case of "Edge-to-Edge" Mitral Valve Plasty Performed for Mitral Regurgitation Associated with Secundum Atrial Septal Defect 　　A. Bito, et al.…48
    A Case of "Edge-to-Edge" Mitral Valve Plasty Performed for Mitral Regurgitation Associated with Secundum Atrial Septal Defect

    (Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan)
    Atsushi Bito Noboru Murata Noboru Yamamoto
    A 33-year-old man presented with respiratory distress and lower leg edema in April 2006. Atrial septal defect (ASD), complicated with moderate mitral regurgitation (MR), advanced tricuspid regurgitation (TR) and pulmonary hypertension (95/32mm Hg), was diagnosed. Qp/Qs was 6.3 and L-R shunt ratio was 84.4%. An "edge-to-edge" mitral valve plasty for MR complication as well as closure of the septal defect and tricuspid annuloplasty was performed, and a good result was obtained. It is known that ASD has a tendency to be accompanied by MR, and the strategy for treatment course for MR is debatable. The mitral lesions of MR complicating ASD are often seen in the posteromedial side of the anterior mitral leaflet, and usually many of the tendinous cords and valve leaflets are in the normal range in length. There have been reports on the mid-term results of edge-to-edge repair of mitral regurgitation due to degenerative lesions but the mid- and long-term results for MR complicating ASD, such as this case are unknown. We need to carefully observe the time course of this case.
    　Jpn. J. Cardiovasc. Surg. 36: 48-51 (2007)
  • A Case of Popliteal Artery Entrapment Precisely Imaged by Multi-Scan Computed Tomography 　　Y. Iida, et al.…52
    A Case of Popliteal Artery Entrapment Precisely Imaged by Multi-Scan Computed Tomography

    (Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Japan)
    Yasunori Iida Tsutomu Sugimoto Takehito Mishima
    Fuyuki Asami Masatake Katsu Kazuo Yamamoto
    Shinpei Yoshii Shigetaka Kasuya
    A 16-year-old high school boy experienced intermittent claudication of his left lower limb during boxing training. Physical examination revealed a cold left foot and diminished pulse. A 64-row multi-slice CT (MSCT) demonstrated lateral shift and severe stenosis of the left popliteal artery due to malposition of the medial head of the gastrocnemius muscle. A diagnosis of popliteal artery entrapment syndrome (Delaney typeII) was established and a surgical correction was planned. During surgery, since the artery was found to be compressed but not occluded, we simply released the popliteal artery by division of the medial head of the gastrocnemius and abnormal flips of muscle. The postoperative ankle brachial pressure index rose from "not measurable" to 1.22. MSCT was useful to characterize this anomaly by expressing the precise anatomical relation of muscle, bone and artery, which was a good guide for an appropriate surgical intervention.
    　Jpn. J. Cardiovasc. Surg. 36: 52-54 (2007)
  • A Case of Cleft Mitral Valve Associated with Papillary Muscle Abnormality in an Adult 　　H. Iida, et al.…55
    A Case of Cleft Mitral Valve Associated with Papillary Muscle Abnormality in an Adult

    (Department of Cardiovascular Surgery, Kimitsu Central Hospital, Kisarazu, Japan and Department of Cardiovascular Surgery, Narita Red Cross Hospital*, Narita, Japan)
    Hiroshi Iida* Yoshio Sudo Hideo Ukita
    Isolated cleft of the anterior mitral leaflet in the presence of an intact atrioventricular septum is a rare cause of mitral regurgitation. We report a surgical case with cleft of the anterior mitral leaflet and abnormality of papillary muscles. A 53-year-old man was admitted to our hospital because of congestive heart failure. Echocardiography showed severe mitral regurgitation, severe tricuspid regurgitation, abnormal direct connection of the anterolateral papillary muscle and the anterior mitral leaflet and adhesion of the base of papillary muscles. At the posterior portion of the anterior leaflet, a 1-cm cleft was found during surgery. The top of the anterolateral papillary muscle adhered to the anterior leaflet, but rheumatic changes were not noted. The cleft was sutured directly, and annuloplasty was performed with a 31-mm Duran flexible ring. Tricuspid annuloplasty was also performed with the DeVega method. His postoperative course was not eventful. Mitral regurgitation caused by mitral cleft associated with abnormal connection of papillary muscles and the mitral leaflet have not been previously reported.
    　Jpn. J. Cardiovasc. Surg. 36: 55-57 (2007)
  • Replacement of a Degenerated Mitral Bioprosthesis Using a Valve-on-Valve Technique 　　T. Furukawa, et al.…58
    Replacement of a Degenerated Mitral Bioprosthesis Using a Valve-on-Valve Technique

    (Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan)
    Tomokuni Furukawa Tatsuhiko Komiya Nobushige Tamura
    Genichi Sakaguchi Chieri Kimura Taira Kobayashi
    Hiromasa Nakamura Akihito Matsushita
    A 79-year-old woman had received implantation of a pace maker for sick sinus syndrome at age 64 and tricuspid valve annuloplasty and Maze at age 68. Furthermore, she underwent tricuspid valve and mitral valve replacement with a bioprosthesis because of tricuspid valve and mitral valve regurgitation at age 73. She was referred to our institution for congestive heart failure in November 2005, because her bioprostheses at the mitral and tricuspid positions had shown significant regurgitation due to the degeneration of the prostheses, which required re-replacement. Because 1) surgical treatment of the heart had been performed twice in the past, 2) the general condition was not good owing to cirrhosis and hypothyroidism and 3) the durability of bioprostheses is short, we performed mitral valve re-replacement by using the "valve-on-valve" technique for reducing the invasion of surgical therapy. She had a satisfactory postoperative course. The "valve-on-valve" technique is a useful option for the re-replacement of bioprosthesis because it obviates the need for removing the sewing ring of the previous bioprosthesis.
    　Jpn. J. Cardiovasc. Surg. 36: 58-62 (2007)