Japanese Journal of Cardiovascular Surgery Vol.36, No.2

Originals

  • Reoperation for Valvular Surgery and Thoracic Aortic Aneurysm Repair with Functioning IMA Grafts after Previous CABG 　　N. Watanabe, et al.……65
    Reoperation for Valvular Surgery and Thoracic Aortic Aneurysm Repair with Functioning IMA Grafts after Previous CABG

    (Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Tokyo, Japan)
    Naruhito Watanabe Satoshi Saito Hideyuki Tomioka
    Kenji Yamazaki Akihiko Kawai Shigeyuki Aomi
    Hiromi Kurosawa
    The use of the internal mammary artery (IMA) is now routine in most coronary artery bypass grafting (CABG) because of its improved long-term patency and survival. A small but important percentage of these patients will require valve surgery and thoracic aortic aneurysm repair following CABG. These operations present a challenging problem for the cardiac surgeon because of difficulties regarding approach, dissection around the IMA and optimal myocardial protection. We investigated surgical results and the effectiveness of various methods of myocardial protection in 8 patients who underwent reoperations between December 1983 and June 2005. The mortality was 13%. There were 2 perioperative myocardial infarctions (25%), 6 cases of prolonged ventilation (75%), 3 cases of low output syndrome (38%), 1 case of acute renal failure (13%) and 1 case of sepsis (13%). We carried out resternotomy for 6 patients without any hospital death or perioperative myocardial infarction. Our reoperation approach had acceptable risk control with resternotomy, avoidance of dissecting the IMA and hypothermic perfusion.
    　Jpn. J. Cardiovasc. Surg. 36: 65-67 (2007)

Case Reports

  • A Case of Platypnea-Orthodeoxia Syndrome Caused by a Patent Foramen Ovale 　　H. Hojo, et al.……68
    A Case of Platypnea-Orthodeoxia Syndrome Caused by a Patent Foramen Ovale

    (Department of Cardiovascular Surgery, Showa General Hospital, Kodaira, Japan, Department of Cardiovascular Surgery, Koga General Hospital*, Miyazaki, Japan and Department of Cardiovascular Surgery, Saitama Medical University**, Saitama, Japan）
    Hiroshi Hojo* Masahiko Ozaki Masanori Ogiwara
    Yuuji Yokote** Shunnei Kyo**
    We encountered a patient with platypnea-orthodeoxia syndrome. This rare syndrome is characterized by right-to-left shunt, which appears in the upright position. A 76-year-old woman with symptomatic hypoxemia was referred for evaluation and treatment. She did not complain of dyspnea while in a supine position, but experienced dyspnea with severe hypoxemia in a sitting or standing position. She did not have any pulmonary diseases that can be cause of dyspnea. Echocardiography revealed a patent foramen ovale and mild left-to-right shunt when the patient was supine. However in an upright position, right-to-left shunt appeared and the arterial oxygen saturation dropped from 95% to 80% with dyspnea. Cardiac catheterization revealed normal pulmonary artery pressure and right-to-left shunt through the patent foramen ovale in the sitting position. We then diagnosed platypnea-orthodeoxia syndrome. The chest CT showed deformity of the right atrium caused by compression of the elongated ascending aorta. The patent foramen ovale was closed and the ascending aorta was shortened by open heart surgery. Her dyspnea and hypoxemia in the upright position was completely resolved after surgery.
    　Jpn. J. Cardiovasc. Surg. 36: 68-71 (2007)
  • Modified Konno Operation for Aortic Valve Regurgitation after Arterial Switch Operation 　　K. Nakamura, et al.……72
    Modified Konno Operation for Aortic Valve Regurgitation after Arterial Switch Operation

    （Department of Cardiovascular Surgery, Jikei University School of Medicine, Tokyo, Japan, Department of Cardiovascular Surgery, Saku Central Hospital*, Saku, Japan and Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University**, Tokyo, Japan）
    Ken Nakamura* Kiyozou Morita Yoshihiro Ko
    Katsushi Kinouchi Kazuhiro Hashimoto Hiromi Kurosawa**
    We describe a case of postoperative aortic valve regurgitation (AR) after arterial awitch operation (ASO) successfully managed by the modified Konno procedure. A 4-year-old girl with complete transposition of the great arteries (TGA, Type II ) had undergone the ASO (LeCompte maneuver) at 10 days of age. Because of progression of moderate AR 4 years after ASO, the modified Konno procedure with aortic valve replacement (SJM 21mm) was successfully performed. She remains in good clinical condition at the last follow-up at 5 years.
    　Jpn. J. Cardiovasc. Surg. 36: 72-75 (2007)
  • Successful Third Surgery in Management of an Aortoesophageal Fistula due to a Thoracic Aortic Aneurysm 　　T. Takagi, et al.……76
    Successful Third Surgery in Management of an Aortoesophageal Fistula due to a Thoracic Aortic Aneurysm

    (Department of Cardiovascular Surgery, Fukui Prefectural Hospital, Fukui, Japan)
    Takeshi Takagi Susumu Fujii Shinichiro Yamamoto
    A 70-year-old man presented at a nearby hospital with dysphagia, hematemesis, and hemorrhage. After examination by magnetic resonance imaging and gastrointestinal fiberscopy, he was referred to our hospital on the suspicion of an aortoesophageal fistula due to a thoracic aortic aneurysm. Considering the degree of invasion and infection, we planned two operations but were compelled to perform three operations because of esophageal leakage. Aortoesophageal fistula due to thoracic aneurysms are usually fatal, with only 18 reported survivors in the past 22 years. The optimal treatment for this condition is not yet known. We report survival of the first case of aortoesophageal fistula due to thoracic aneurysm complicated by mediastinitis caused by esophageal leakage in which management by two operations was initially planned. From this case many possible strategies to manage aortoesophageal fistula due to thoracic aneurysms arose. Therefore, we report this case together with a review of the literature.
    　Jpn. J. Cardiovasc. Surg. 36: 76-80 (2007)
  • A Patient with Valvular Heart Disease and Parkinson’s Disease: Prevention of Neuroleptic Malignant Syndrome 　　K. Nakamura, et al.……81
    A Patient with Valvular Heart Disease and Parkinson’s Disease: Prevention of Neuroleptic Malignant Syndrome

    (Department of Cardiovascular Surgery, Jikei University Kashiwa Hospital, Kashiwa, Japan, Department of Cardiovascular Surgery, Saku Central Hospital*, Saku, Japan and Department of Cardiovascular Surgery, Jikei University School of Medicine**, Tokyo, Japan)
    Ken Nakamura* Keno Mashiko Shinichi Ishii**
    Kunihiro Naganuma Kazuhiro Hashimoto**
    The patient was a 71-year-old man who had been treated for Parkinson’s disease for 21 years. He was admitted because nocturnal dyspnea occurred several times. Echocardiography revealed congestive heart failure because of combined mitral and aortic regurgitation. Double valve replacement was planned. There was a risk of the occurrence of neuroleptic malignant syndrome (NMS) if his drugs for Parkinson’s disease were stopped suddenly, so careful control of drug doses was required. Although the patient developed aggravation of his Parkinson’s symptoms, careful observation and adjustment of medications prevented the occurrence of NMS.
    　Jpn. J. Cardiovasc. Surg. 36: 81-84 (2007)
  • Tricuspid Valve Endocarditis Complicated Disseminated Intravascular Coagulation (DIC) before an Operation 　　D. Futagami, et al.……85
    Tricuspid Valve Endocarditis Complicated Disseminated Intravascular Coagulation (DIC) before an Operation

    (Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan)
    Daisuke Futagami Hideo Yoshida Hironori Ebishima
    Nobuyuki Tokunaga Keiji Yunoki Kunikazu Hisamochi
    Osamu Oba
    Right-sided infective endocarditis (IE) accounts for 5% to 10% of all IE. Compared with left-sided IE, antibiotic treatment is effective in about 70% of cases. The timing of surgical treatment for right-sided IE is therefor controversial. A 26-year-old woman had suffered from tricuspid valve endocarditis with DIC. There was no evidence of any previous cardiac event or dental treatment. Echocardiography showed a large vegetation attached to the anterior leaflet of tricuspid valve with moderate tricuspid regurgitation. We removed the vegetation with a part of the anterior leaflet and performed tricuspid valvuloplasty and annuloplasty. The patient had an uneventful postoperative course and received intravenous antibiotic treatment for a further 4 weeks.
    　Jpn. J. Cardiovasc. Surg. 36: 85-87 (2007)
  • Aortic Arch Replacement for Thoracic Aortic Aneurysm Combined with Aberrant Right Subclavian Artery: Two Case Reports 　　H. Kanamitsu, et al.……88
    Aortic Arch Replacement for Thoracic Aortic Aneurysm Combined with Aberrant Right Subclavian Artery: Two Case Reports

    (Department of Cardiovascular Surgery, Cardiovascular Center Sakakibara Hospital, Okayama, Japan)
    Hitoshi Kanamitsu Hidenori Yoshitaka Masahiko Kuinose
    Yoshimasa Tsushima Hitoshi Minami Toshinori Totsugawa
    Masamichi Ozawa
    We present two cases of thoracic aortic aneurysm combined with aberrant right subclavian artery. Case 1 was a 71-year-old man, and case 2 was a 74-year-old man with an aortic arch aneurysm associated with a diverticulum of Kommerell. In both cases, we performed total aortic arch replacement through median sternotomy using cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion. We reconstructed all 4 arch branches. The aberrant right subclavian artery arose from the distal portion of the aortic arch, distal to the origin of the left subclavian artery. It crossed the midline between the esophagus and spine. To prevent compression of the trachea and esophagus by the right subclavian artery, we reconstructed it by the anterior side of the trachea. The postoperative course was uneventful.
    　Jpn. J. Cardiovasc. Surg. 36: 88-91 (2007)
  • A Case of Concomitant Coronary Artery Disease, Abdominal Aortic Aneurysm, and Bile Duct Cancer 　　S. Shioguchi, et al.……92
    A Case of Concomitant Coronary Artery Disease, Abdominal Aortic Aneurysm, and Bile Duct Cancer

    (Department of Cardiovascular Surgery, Koshigaya Hospital Dokkyo University School of Medicine, Koshigaya, Japan)
    Soichi Shioguchi Yoshihito Irie Shigeyoshi Gon
    Koyu Tanaka Takao Imazeki
    We report a rare case of concomitant coronary artery disease, abdominal aortic aneurysm, and bile duct cancer. A 65-year-old man, who had been recognized to have jaundice in late November 2005, was found to have bile duct cancer, an abdominal aortic aneurysm with a diameter of 70mm, and coronary artery disease (with two severely diseased branches). To avoid extended operation, a two-stage operation was performed; at the first operation, off-pump coronary artery bypass surgery (LITA to LAD and Ao-SVG to 4PD) and replacement of the abdominal aortic aneurysm by an artificial blood vessel with minimal incision were implemented. In 21 days after the cardiovascular surgery, the patient underwent pylorus-preserving pancreatoduodenectomy (modified Child method) in the second operation. After the two-stage operation, the patient showed a favorable outcome without any major complications. On the basis of the outcome of two-stage operation we successfully applied, we discuss the strategy for treatment of patients having both cardiovascular and abdominal malignant diseases, with reference to the literature.
    　Jpn. J. Cardiovasc. Surg. 36: 92-95 (2007)
  • Ruptured Saccular Aneurysm Associated with a Coronary Artery to Pulmonary Artery Fistula 　　H. Hojo, et al.……96
    Ruptured Saccular Aneurysm Associated with a Coronary Artery to Pulmonary Artery Fistula

    (Department of Cardiovascular Surgery, Showa General Hospital, Kodaira, Japan, Department of Cardiovascular Surgery, Koga General Hospital*, Miyazaki, Japan and Department of Cardiovascular Surgery, Saitama Medical University**, Saitama, Japan)
    Hiroshi Hojo* Masahiko Ozaki Masanori Ogiwara
    Yuuji Yokote** Shunnei Kyo**
    We report successful operative treatment of a ruptured coronary artery saccular aneurysm associated with a coronary-pulmonary artery fistula. A 66-year-old woman experienced sudden onset of unconsciousness due to cardiac tamponade. Echocardiogram and chest CT on admission showed pericardial effusion and a 50-mm diameter saccular coronary artery aneurysm. Coronary angiogram revealed coronary artery aneurysm which arose on the conus branch of the right coronary artery. The connection between the aneurysm and the pulmonary artery was not clarified. Cardiac tamponade due to rupture of the saccular coronary artery aneurysm was suspected and emergency operation was performed. Operative findings revealed coronary-pulmonary artery fistula. Closure of the orifice of the draining artery to the pulmonary artery, and aneurysmorrhaphy were performed. Postoperative coronary angiogram and chest CT showed no residual fistula, and the postoperative course was uneventful.
    　Jpn. J. Cardiovasc. Surg. 36: 96-99 (2007)
  • A Case of Total Right Heart Bypass Operation for Polysplenia with Diffuse Bilateral Pulmonary Arteriovenous Fistula and Left Pulmonary Vein Obstruction by Anterior Translocation of the Hemiazygos Vein and Direct Anastomosis of the Hemiazygos Vein to the Hepatic Vein 　　T. Nakata, et al.……100
    A Case of Total Right Heart Bypass Operation for Polysplenia with Diffuse Bilateral Pulmonary Arteriovenous Fistula and Left Pulmonary Vein Obstruction by Anterior Translocation of the Hemiazygos Vein and Direct Anastomosis of the Hemiazygos Vein to the Hepatic Vein

    (Department of Cardiovascular Surgery, Shizuoka Children’s Hospital, Shizuoka, Japan)
    Tomohiro Nakata Akio Ikai Yoshifumi Fujimotoi
    Noritaka Ota Masaya Murata Kisaburo Sakamoto
    Diffuse bilateral pulmonary arteriovenous fistula (PAVF) developed in a 19-month-old girl with polysplenia, single atrium, single right ventricle, left superior vena cava and interrupted inferior vena cava (IVC) after total cavopulmonary shunt (TCPS) operation. In addition, left pulmonary vein obstruction (PVO) by compression between the dilated hemiazygos vein and the atrium was identified. We performed total right heart bypass operation with anterior translocation of the hemiazygos vein for release of PVO and direct anastomosis of the hemiazygos vein to the hepatic vein to divert hepatic venous flow to the bilateral pulmonary circulation. Follow-up cardiac catheterization 9 months later showed disappearance of PAVF and no stenotic region. The merits of this operation are: 1)to provide balanced distribution of hepatic venous flow through the hemiazygos vein to the pulmonary circulation, 2)to release the PVO caused by the dilated hemiazygos vein, and 3)to allow for potential growth. This operation can be performed to Fontan candidates with interrupted IVC.
    　Jpn. J. Cardiovasc. Surg. 36: 100-104 (2007)
  • Case Report of Spontaneous Rupture of the Inferior Vena Cava Associated with Infrarenal Abdominal Aortic Aneurysm 　　M. Hamaji, et al.……105
    Case Report of Spontaneous Rupture of the Inferior Vena Cava Associated with Infrarenal Abdominal Aortic Aneurysm

    (Department of Cardiovascular Surgery, Nagahama City Hospital, Nagahama, Japan)
    Masatsugu Hamaji Satoshi Kono Mitsuhiko Matsuda
    Spontaneous formation of aorto-caval fistulae is rare, occurring only in 4% of all ruptured abdominal aneurysms, and spontaneous rupture of the inferior vena cava (IVC) associated with the unruptured abdominal aneurysm has not been previously found in the literature. A 79-year-old woman with abdominal pain and hemorrhagic shock, was found to have a leaking abdominal aortic aneurysm and was transferred to our hospital. Preoperative CT revealed a massive right retroperitoneal hematoma and an infrarenal large abdominal aortic aneurysm. At laparotomy, no leaking site was found in the aneurysm, but a 2-cm laceration in the wall of IVC was found. The injured site was closed with a patch while controlling bleeding with a balloon catheter. The patient recovered uneventfully and was discharged on the 17th postoperative day. The mechanism of spontaneous rupture of the IVC is unknown, but and may occur due to incidental and abrupt increase in venous pressure in a stenotic IVC.
    　Jpn. J. Cardiovasc. Surg. 36: 105-107 (2007)
  • A Case of Re-Dissection of Aortic Root after Reconstruction of Acute Aortic Dissection 　　S. Matsuyama, et al.……108
    A Case of Re-Dissection of Aortic Root after Reconstruction of Acute Aortic Dissection

    (Division of Cardiovascular Surgery, Fukuoka Wajiro Hospital, Fukuoka, Japan)
    Shigefumi Matsuyama Yoshito Kawachi Kazuyoshi Doi
    Masakatsu Hamada
    A 69-year-old man had been treated with total arch replacement for acute Stanford type A aortic dissection. He had cardiac failure at 9 years after his previous operation. Computed tomography and transesophageal echocardiography showed re-dissection of the aortic root and aortic regurgitation. He was referred to our hospital for surgical treatment. In the second operation, aortic root replacement was performed. Re-dissection of the aortic root at the site of the non-coronary sinus was noted intraoperatively, and intraoperative findings suggested necrosis of the aortic wall related to the use of GRF glue. Care should be taken to ensure proper use of GRF glue. The aortic root replacement using a Freestyle valve provided good hemodynamic function and low thrombogenicity. The use of this valve in this case which had residual dissection of the descending aorta seemed useful because of the excellent hemodynamic function without anticoagulant therapy.
    　Jpn. J. Cardiovasc. Surg. 36: 108-111 (2007)
  • Aortic Valve Replacement for Porcelain Aorta with Balloon Occlusion and Deep Hypothermic Circulatory Arrest 　　T. Murakami, et al.……112
    Aortic Valve Replacement for Porcelain Aorta with Balloon Occlusion and Deep Hypothermic Circulatory Arrest

    (Department of Cardiovascular Surgery, Oji General Hospital, Tomakomai, Japan)
    Tatsuya Murakami Hiroki Kato Yutaka Makino
    A 78-year-old woman on chronic hemodialysis was found to have severe aortic stenosis causing refractory hypotension during hemodialysis and elected to undergo aortic valve replacement. However, chest CT scan revealed a totally calcified “porcelain” ascending aorta which prevented safe aortic cross-clamping. MRA also showed stenosis of the origin of the left subclavian artery. At operation, an area free from calcification was identified in the lesser curvature of the ascending aorta where an aortic cannula was placed. Cardiopulmonary bypass was commenced. A single selective cerebral perfusion was added via the left axillary artery to maintain adequate flow to the dominant left vertebral artery. The patient was cooled to a rectal temperature of 24℃ when a proximal transverse aortotomy was made and an occlusion balloon was inserted into the ascending aorta during circulatory arrest for 2min. The cardiopulmonary bypass was restarted with half systemic flow. The aortic valve was excised and a 19-mm Carpentier-Edwards bovine pericardial valve was placed in the supravalvular position with simple interrupted sutures. The body was further cooled down to 19℃. On another circulatory arrest, the balloon was removed. Endarterectomy was performed along the edges of the aortotomy which was reinforced with equine pericardial strips. The aortotomy was then closed with a running suture. The circulation was restarted and the patient was rewarmed. Circulatory arrest time was 42min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications. The operative technique described here for the treatment of aortic valve disease in a patient with a porcelain aorta is safer than deep hypothermic circulatory arrest alone, allowing shorter circulatory arrest period. In addition, endarterectomy of the aortotomy edges reinforced with xenopericardial strips is useful to secure the closure line against bleeding.
    　Jpn. J. Cardiovasc. Surg. 36: 112-116 (2007)