Japanese Journal of Cardiovascular Surgery Vol.36, No.3

Originals

  • Assessment of Pulse Wave Velocity as a Marker of Postoperative Cardiovascular Risk in CABG Patients 　　T. Sugimoto, et al.……117
    Assessment of Pulse Wave Velocity as a Marker of Postoperative Cardiovascular Risk in CABG Patients

    (Department of Cardiovascular Surgery, Tachikawa Medical Center, Nagaoka, Japan)
    Tsutomu Sugimoto Kazuo Yamamoto Koji Shimada
    Masatake Katsu Yasunori Iida Takehito Mishima
    Fuyuki Asami Shinpei Yoshii Shigetaka Kasuya
    Pulse wave velocity is widely used as an index of arterial stiffness. The aim of this study is to assess the usefulness of pulse wave velocity as a risk factor in patients who underwent coronary artery bypass grafting. Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV) and the ratio of the patient’s baPWV to the age-matched normal value was calculated in 42 CABG patients. Age and male/female ratios were 66.7 years and 33/9, respectively. baPWV (1,820.7±459.8cm/s) was higher in CABG patients than that in age-matched normal value. Preoperatively, the baPWV ratio in the group with the history of cerebrovascular disease was significantly higher than that in the group who had no cerebrovascular disease (p＜0.05). 　In contrast, the baPWV ratio did not correlate to the severity of other cardiovascular diseases. There was one (2.4%) in-hospital death and 23 incidences of postoperative complication in 16 patients. The baPWV ratio in the group with postoperative complications was significantly higher than that in the group with no complications (1.38±0.33 vs.1.16±0.22; p＜0.05). In this study, baPWV in CABG patients was higher compared with that in the age-matched general population, indicating the existence of atherosclerotic vascular changes. The elevated bePWV is also a risk factor of postoperative complications in patients who have undergone CABG.
    　Jpn. J. Cardiovasc. Surg. 36: 117-120 (2007)
  • Evaluation of Hypercoagulable Status after Off-Pump Coronary Artery Bypass Using Platelet-Derived Microparticles 　　H. Yamauchi, et al.……121
    Evaluation of Hypercoagulable Status after Off-Pump Coronary Artery Bypass Using Platelet-Derived Microparticles

    (Department of Cardiovascular Surgery, Obihiro Kousei General Hospital, Obihiro, Japan and Department of Cardiovascular Surgery, Hokkaido University Hospital*, Sapporo, Japan)
    Hidetoshi Yamauchi Masamichi Ito Toru Watanabe
    Hiroyuki Satoh Yoshiro Matsui*
    Thromboembolic events after cardiac surgery, including ischemic strokes, can be devastating complications, however only a few studies manifest the platelet activation and coagulation state after off-pump coronary artery bypass (OPCAB). Platelet-derived microparticles (PMP) are observed as released vesicles from platelets following platelet activation, and are believed to play a role in some clinical diseases because of their procoagulant activity. The aim of the present study was to evaluate the hypercoagulant state after OPCAB using PMP and other indices. Data were obtained from 15 patients (aged 69±7 years; only men) undergoing elective OPCAB surgery. One hundred milligrams of aspirin were used as postoperative antiplatelet drugs. Preoperative risk factors, operation time, postoperative hospital stay, transfusion and blood samples of CBC, PMP, βTG, PF4, platelet aggregation, FDP, D-dimer and TAT of pre- and postoperative days (POD) 3 and 7 were studied. There was no difference between the PMP level with or without risk factor. The PMP levels of POD 3 and 7 were significantly higher compared to the preoperative levels (pre-op, POD 3, 7: 9.1±5.1, 15.2±10.3, 28.4±24.5/104plt respectively, p＜0.05). The levels of FDP, D-dimer and TAT rose significantly on POD 3 and 7 and significantly correlated with the PMP levels. Beta TG, PF4 and platelet aggregation did not change after OPCAB surgery, and no correlation was found with the PMP levels. Elevated levels of PMP, TAT, FDP and D-dimer persisted until POD 7 and suggested not only platelet activation, but also activation of the coagulation and fibrinolytic system. The findings suggest that 100mg of aspirin may not be adequate for the inhibition of platelet activation after OPCAB surgery.
    　Jpn. J. Cardiovasc. Surg. 36: 121-126 (2007)

Case Reports

  • Aortic Dissection Caused by the Right Axillary Artery Perfusion 　　M. Hatakeyama, et al.……127
    Aortic Dissection Caused by the Right Axillary Artery Perfusion

    (Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan)
    Masaharu Hatakeyama Ikuo Fukuda Satoshi Taniguchi
    Kazuyuki Daitoku Masahito Minakawa Yasuyuki Suzuki
    Kozo Fukui
    Aortic dissection during cardiac operation is a rare but serious complication. Early detection and adequate repair is essential in this situation. A 69-year-old man in whom an aortic valve sparing operation for aortic root dilatation with aortic regurgitation had been begun, had an intraoperative aortic dissection 10 min after the start of right axillary artery perfusion. Intraoperative transesophageal echocardiography and direct epi-aortic echo revealed acute aortic dissection extending from the aortic root to at least the descending aorta. The dissection was successfully repaired by a Bentall operation and hemiarch replacement using hypothermic circulatory arrest, selective cerebral perfusion, and antegrade perfusion from an anastomosed graft.
    　Jpn. J. Cardiovasc. Surg. 36: 127-131 (2007)
  • A Successful Case of Ascending Aorta-Abdominal Aorta Bypass in a Patient with Atypical Coarctation 　　M. Tanaka, et al.……132
    A Successful Case of Ascending Aorta-Abdominal Aorta Bypass in a Patient with Atypical Coarctation

    (Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan and Department of Cardiovascular Surgery, Kumamoto University Hospital*, Kumamoto, Japan)
    Mutsuo Tanaka* Toitsu Hirayama Hiroaki Yusa
    Ichiro Ideta Hideyuki Uesugi Yasuhiro Shimokawa
    Hiroyasu Misumi
    A 69-year-old woman was admitted with severe hypertension and intermittent claudication. The results of further examination, showed that the hypertension and intermittent claudication were due to stenosis of the descending aorta and we diagnosed atypical aortic coarctation. We performed median sternotomy and ventrotomy with side-to-end anastomosis a woven Dacron graft and the ascending aorta. The graft was passed through the lesser omentum, and mesocolon and to abdominal aorta. The postoperative state was stable, and the hypertension and intermittent claudication were remarkably ameliorated. Many cases of extra-anatomical bypass were reported, and the ascending aorta-abdominal aorta bypass was useful method and, very successful with no complications in this case.
    　Jpn. J. Cardiovasc. Surg. 36: 132-136 (2007)
  • A Case of Multiple Coronary Artery Aneurysms Associated with Bilateral Coronary-Pulmonary Artery Fistulae 　　N. Sasahashi, et al.……137
    A Case of Multiple Coronary Artery Aneurysms Associated with Bilateral Coronary-Pulmonary Artery Fistulae

    (Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan and Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center*, Kyoto, Japan）
    Nozomu Sasahashi* Toshifumi Takeuchi Masahira Fukuoka
    A case of multiple coronary artery aneurysms associated with bilateral coronary-pulmonary artery fistulae is described. A 60-year-old man was found to have a continuous heart murmur. Plain chest X-ray showed mild cardiomegaly and an abnormal shadow at the left periphery of the heart. Enhanced chest CT revealed multiple round masses around the main pulmonary artery. Cardiac catheterization studies confirmed the presence of a left-to-right shunt of 26% at the site of the main pulmonary artery, with a pulmonary-to-systemic flow ratio of 1.35: 1. Coronary angiography revealed multiple coronary artery aneurysms associated with bilateral coronary-pulmonary artery fistulae and an abnormal coronary artery adjacent to the right coronary artery. Mild aortic regurgitation was also noted on ascending aortography. On February 10, 2006, surgical intervention was undergone. The maximum diameter of the coronary artery aneurysms was 4cm and the aneurysmal wall was very thin. Dilated abnormal vessels connected with the aneurysms were also noted. Under complete cardiopulmonary bypass, extirpation of the aneurysms and ligation of the abnormal vessels were performed. Although the main pulmonary artery was opened to inspect the draining portion from the fistula, the orifice could not be confirmed. The aortic valve was replaced with a mechanical prosthesis. Histopathological findings of the excised specimen included fibrosis, myxoid change, and calcification. The postoperative clinical course was uneventful, and no residual mass was noted on chest CT. The patient was discharged on the 14th postoperative day.
    　Jpn. J. Cardiovasc. Surg. 36: 137-140 (2007)
  • Graft Replacement of an Abdominal Aortic Aneurysm Previously Treated by Endovascular Stent Grafting in Two Cases 　　T. Ito, et al.……141
    Graft Replacement of an Abdominal Aortic Aneurysm Previously Treated by Endovascular Stent Grafting in Two Cases

    (Department of Thoracic and Cardiovascular Surgery and Division of Traumatology and Critical Care Medicine*, Sapporo Medical University, Sapporo, Japan)
    Toshiro Ito Nobuyoshi Kawaharada Yoshihiko Kurimoto*
    Kenji Kuwaki Ryou Harada Yousuke Kuroda
    Kiyohumi Morishita Tetsuya Higami
    Ninety patients with abdominal aortic aneurysm underwent endovascular stent grafting in our hospital between 2001 and 2006 and two patients required graft replacement of abdominal aortic aneurysms during the late postoperative phase. Case 1 was a 77-year-old man for whom endovascular stent grafting for an abdominal aortic aneurysm and thoracic aortic aneurysm had been performed concomitantly. Six months later, because the abdominal aortic aneurysm had expanded from 68mm to 75mm in diameter, due to a type I endoleak which was detected postoperatively, he underwent open surgery. An occlusion balloon was inflated at the proximal site of the celiac artery until the stent graft was extracted. After positioning the aortic clamp below the origin of the renal arteries, a bifurcated graft was implanted. The postoperative course was uneventful. Case 2 was an 86-year-old woman who had undergone endovascular stent grafting for an abdominal aortic aneurysm. The endovascular procedure was successful and no endoleak was detected postoperatively. However, 13 months later, a community hospital admitted her in a state of shock due to ruptured abdominal aortic aneurysm. She was transferred to our hospital and underwent an emergency operation. Because insertion of an occlusion balloon into the brachial artery failed, we primarily performed supravisceral aortic cross clamping. After opening the aneurysm sac, the stent graft was removed and a bifurcated graft was implanted. After declamping, we found that the right common iliac artery was occluded, and therefore aorto-right external iliac bypass grafting was then also performed. The postoperative course was uneventful.
    　Jpn. J. Cardiovasc. Surg. 36: 141-144（2007)
  • A Rescue Case of Left Ventricular Free Wall Rupture after Acute Myocardial Infarction Using the David-Komeda Method 　　R. Suzuki, et al.……145
    A Rescue Case of Left Ventricular Free Wall Rupture after Acute Myocardial Infarction Using the David-Komeda Method

    (Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan)
    Ryusuke Suzuki Toshiya Koyanagi Toshiaki Watanabe
    Ryo Hirayama Ichiro Nohata
    A 61-year-old woman developed shock during transportation to our hospital in an ambulance under a diagnosis of acute myocardial infarction, Emergency coronary angiography showed left anterior interventricular descending branch＃6 to be completely occluded. At the same time, ultrasonic cardiography showed pericardial effusion. Therefore we diagnosed left ventricular free wall rupture, and performed emergency surgery to repair the rupture site. After pericardiotomy massive hemorrhage occurred and we diagnosed blow-out type left ventricular free wall rupture. We immediately established extracorporeal circulation via the femoral artery and vein, and cross clamped the ascending aorta, then achieved cardiac arrest. Because the area of myocardial infarction was extensive, we applied the David-Komeda method to avoid bleeding due to left ventricular systolic pressure, left ventricular aneurysm or ventricular septal rupture. The postoperative course was good; the patient was weaned from PCPS on the 3rd day postoperatively, IABP on the 5th day postoperatively and from the respirator on the 8th day postoperatively. She was discharged on postoperative day 40. Currently she has no cardiac complains, no left ventricular aneurysm and no neurological problems. Left ventricular free wall rupture can remain a fatal complication after acute myocardial infarction. We consider the David-Komeda method useful for repairing left ventricular free wall rupture (blow-out type) after acute myocardial infarction as well as ventricular septal rupture without a risk of left ventricular aneurysm, bleeding or ventricular septal wall rupture.
    　Jpn. J. Cardiovasc. Surg. 36: 145-149（2007)
  • A Case of Expansion of a Right Internal Iliac Artery Aneurysm after an Exclusion Operation 　　T. Baba, et al.……150
    A Case of Expansion of a Right Internal Iliac Artery Aneurysm after an Exclusion Operation

    (Department of Cardiovascular Surgery, Hoshigaura Hospital, Kushiro, Japan)
    Toshio Baba Hideyuki Harada Kazuhiro Takahashi
    This is a case report of an expansion of the right internal iliac artery aneurysm after an exclusion operation. A 72-year-old man, had undergone aneurysmectomy and graft replacement of a right external iliac artery aneurysm and a ruptured left iliac artery aneurysm, and exclusion of a right internal iliac artery aneurysm in1995. Computed tomography showed an expansion of the right internal iliac artery aneurysm in 2003. We performed graft replacement and bypassing to the right external iliac artery. The patient had a satisfactory postoperative course.
    　Jpn. J. Cardiovasc. Surg. 36: 150-152 (2007)
  • An Elderly Case of Ruptured Aortic Arch Aneurysm with Hemorrhagic Cardiac Tamponade 　　Y. Yamada, et al.……153
    An Elderly Case of Ruptured Aortic Arch Aneurysm with Hemorrhagic Cardiac Tamponade

    (Department of Cardiothoracic Surgery, Dokkyo Medical University, Tochigi, Japan)
    Yasuyuki Yamada Yoshihiko Mochizuki Yoshiei Shimamura
    Kunihiro Eda Ikuko Shibasaki Yuhou Inoue
    Shinichiro Miyoshi
    An 82-year-old man was taken to a local clinic following the occurrence of syncope. Chest roentgenography and computed tomography (CT) findings led to a suspicion of a ruptured aortic aneurysm, and the patient was immediately transferred to our hospital. Upon admission, his consciousness was clear and blood pressure was 74/47mmHg. Enhanced chest CT images demonstrated pericardial effusion and a saccular aneurysm with a maximum diameter of 5cm, which was associated with a thrombus in the distal aortic arch. An emergency operation was performed under a diagnosis of a ruptured distal aortic arch aneurysm and hemorrhagic cardiac tamponade. During the procedure, a hole was found in the lesser curvature of the aneurysm, which had directly ruptured into the pericardial space, and a graft replacement of the aortic arch was performed using selective cerebral perfusion. The patient was discharged 19 days after surgery without any postoperative complications.
    　Jpn. J. Cardiovasc. Surg. 36: 153-156 (2007)
  • A Case of Subacute Stent Thrombosis during Perioperative Period of Off-Pump Coronary Artery Bypass Grafting after Successful Sirolimus-Eluting Stent Implantation 　　M. Umesue, et al.……157
    A Case of Subacute Stent Thrombosis during Perioperative Period of Off-Pump Coronary Artery Bypass Grafting after Successful Sirolimus-Eluting Stent Implantation

    (Cardiovascular Surgery and Cardiology*, Matsuyama Red Cross Hospital, Matsuyama, Japan)
    Masayoshi Umesue Koji Matsuzaki Hiromichi Sonoda
    Kanzi Matsui Tetsuya Shiomi* Toshiaki Ashihara*
    A 76-year-old man received implantation of sirolimus-eluting stent for total occlusion of the left circumflex artery causing an acute myocardial infarction of posterolateral wall on May 21st, 2005. Off-pump coronary artery bypass grafting was performed on June 9th for a residual 90% stenosis on the proximal segment of his left anterior descending artery. Ticlopidine and aspirin were discontinued 7 days and 2 days before the operation, respectively. Continuous intravenous drip of heparin had been given for 5 days until just prior to the operation. Though the left internal thoracic artery was successfully grafted onto the left anterior descending artery, he developed an acute myocardial infarction after the operation. An emergency angiography, performed on the 1st postoperative day showed thrombotic occlusion of the sirolimus-eluting stent in the circumflex artery and patent internal thoracic artery to the left anterior descending artery. Percutaneous catheter intervention restored the stent patency. Antiplatelet therapy including ticlopidine or clopidogrel is mandatory to prevent subacute thrombosis in drug-eluting stent. Hemorrhagic complication or major surgery may hinder continuing antiplatelet regimens and trigger acute thrombosis. Alternative antiplatelet and/or anticoagulant therapy is essential to prevent acute stent occlusion in such clinical settings.
    　Jpn. J. Cardiovasc. Surg. 36: 157-161 (2007)
  • A Surgical Case of Type B Aortic Dissection with Concomitant Distal Aortic Arch Aneurysm 　　K. Takigami, et al.……162
    A Surgical Case of Type B Aortic Dissection with Concomitant Distal Aortic Arch Aneurysm

    (Department of Cardiovascular Surgery, NTT East Corporation Sapporo Hospital, Sapporo, Japan)
    Ko Takigami Masatoshi Motohashi Akira Adachi
    Keishu Yasuda
    A 70-year-old man was given emergency admission with severe back pain. Computer tomography revealed type-B acute aortic dissection with a distal aortic arch aneurysm which was 69mm in diameter. The dissection extended from the distal portion of the aneurysm to right external iliac artery, and the false lumen was patent. The right renal artery arose from the false lumen. He was treated conservatively according to the guidelines of AHA, and later we performed total arch replacement electively for the aortic arch aneurysm. Distal anastomosis was applied using the elephant trunk method for reconstruction of only the true lumen. Postoperative computer tomography showed the false lumen was closed in the descending thoracic aorta, but patent below the level of the celiac artery. He was discharged without any complications. Cases of acute aortic dissection coexisting with atherosclerotic thoracic aortic aneurysm are rare. However, with the increase of the elderly population, vascular diseases will become more complicated. Strategy for therapy and operation should be considered carefully especially in such cases with multiple vascular diseases.
    　Jpn. J. Cardiovasc. Surg. 36: 162-165 (2007)
  • A Case of Emergency Off-Pump Coronary Artery Bypass Grafting after DES Stenting 　　H. Iwahashi, et al.……166
    A Case of Emergency Off-Pump Coronary Artery Bypass Grafting after DES Stenting

    (Department of Cardiovascular Surgery, Fukuoka University, School of Medicine, Fukuoka, Japan)
    Hidehiko Iwahashi Tadashi Tashiro Noritsugu Morishige
    Yoshio Hayashida Kazuma Takeuchi Nobuhisa Ito
    Koji Akasu Go Kuwahara
    A 75-year-old man was admitted with symptoms of unstable angina pectoris. The patient was initially treated with ticlopidine and aspirin after first undergoing percutaneous coronary intervention (PCI) by means of a drug eluting stent (DES). Coronary angiography thereafter showed re-stenosis in left main trunk and two-vessel disease. As a result, emergency off-pump coronary artery bypass grafting (OPCAB) was therefore performed. However, major bleeding (3,245ml) occurred after OPCAB. Therefore, a re-thoracotomy operation had to be performed to stop the bleeding. Based on the above findings it is important for surgeons to keep in mind that pre-operative ticlopidine administration can increase the risk of re-operation for hemostasis, while also potentially increasing and the requirements for blood and blood product transfusion both during and after OPCAB surgery.
    　Jpn. J. Cardiovasc. Surg. 36: 166-169 (2007)
  • A Case of Acute Aortic Dissection after Aortic Valve Replacement for Aortic Stenosis 　　T. Fujimatsu, et al.……170
    A Case of Acute Aortic Dissection after Aortic Valve Replacement for Aortic Stenosis

    (Department of Cardiovascular Surgery, Heart Center, Aizawa Hospital, Matsumoto, Japan)
    Toshihiro Fujimatsu Hajime Osawa Fumie Takai
    A63-year-old man who underwent aortic valve replacement (AVR) for aortic stenosis (AS) associated with mildly dilated ascending aorta 28 months previously was admitted to our hospital because of severe chest pain. Computer tomography showed aortic dissection expanding from the sinus of Valsalva to the abdominal aorta. Bentall’s procedure and ascending aorta-aortic arch replacement were successfully performed and his postoperative course was uneventful. The surgical management of patients with aortic stenosis associated with ascending aortic dilatation is a controversial issue. We think that Bentall’s procedure may be considered as one of the strategies for AS associated with moderate dilation of the aortic root (≧50mm diameter). Following AVR, we should have regularly controlled the patient by ultrasonic cadiogram (UCG) and electively reperformed Bentall’s procedure when progression of the enlargement of aortic root had been detected.
    　Jpn. J. Cardiovasc. Surg. 36: 170-173 (2007)