Japanese Journal of Cardiovascular Surgery Vol.36, No.4

Originals

Risk Factors for Deep Sternal Wound Infection after Coronary Artery Bypass Grafting 　　H. Masumoto, et al.……175

Risk Factors for Deep Sternal Wound Infection after Coronary Artery Bypass Grafting

(Department of Cardiovascular Surgery, Shizuoka City Hospital, Shizuoka, Japan)

Hidetoshi Masumoto Mitsuomi Shimamoto Fumio Yamazaki

Masanao Nakai Shoji Fujita Tatsuya Itonaga

Deep sternal wound infection (DSWI) following coronary artery bypass grafting (CABG) is associated with a high rate of mortality and is therefore considered a serious complication. In the present study, we investigated the risk factors for post-CABG DSWI. The subjects were 171 patients who underwent CABG via median sternotomy out of 173 consecutive patients who underwent isolated CABG at our department between January and December 2003. There were 3 (1.8%) in-hospital deaths. Univariate analysis was initially performed on each of the independent factors for DSWI, and multivariate analysis was then performed using binomial logistic regression analysis with the independent factors as covariables on the independent variables that reached statistical significance. DSWI was observed in 8 patients (4.7%), 1 (12.5%) of whom died in the hospital. Five (62.5%) of the 8 patients were given a diagnosis of mediastinitis. The results of univariate analysis revealed statistical significance (p＜0.05) for the following independent factors: diabetes (oral drug therapy), aortic clamping time (although only 97 patients who underwent aortic cross clamp were included in the analysis), homologous blood transfusion, reexploration for bleeding, long-term intubation or reintubation, maximum blood glucose level after surgery, and a positive blood culture. Multivariate analyses were performed on these factors (except for aortic clamping time) that were statistically significant in the univariate analysis using the factors as covariables. A positive blood culture (odds ratio 142.2; p＝0.001; 95% confidence interval, 7.2-2799.8) and reexploration for bleeding (odds ratio 36.7; p＝0.019; 95% confidence interval, 1.8-747.5) were found to be significant independent risk factors for post-CABG DSWI. We identified multiple risk factors related to DSWI.
　Jpn. J. Cardiovasc. Surg. 36: 175-179 (2007)

Case Reports

Deep Vein Thrombosis following Y-Graft Replacement for Abdominal Aortic Aneurysm after Splenectomy in a Case of Chronic Idiopathic Thrombocytopenic Purpura 　　S. Kuze and H. Fujita……180

Deep Vein Thrombosis following Y-Graft Replacement for Abdominal Aortic Aneurysm after Splenectomy in a Case of Chronic Idiopathic Thrombocytopenic Purpura

(Department of Surgery, Iwata Municipal General Hospital, Iwata, Japan, Department of Vascular Surgery, Fukuroi City Hospital*, Fukuroi, Japan and Department of Vascular Surgery, Nagoya University**, Nagoya, Japan)

Shingo Kuze* Hiromine Fujita**

A 73-year-old man underwent splenectomy for treatment of chronic idiopathic thrombocytopenic purpura (ITP), but platelet count decreased again. An infrarenal abdominal aortic aneurysm (AAA) with a diameter of 3.9cm had been pointed out at splenectomy. Because follow up CT showed the diameter of the AAA to exceed 5cm, Y-graft replacement of the infrarenal AAA was performed following preoperative immunoglobulin infusion therapy. A year later he suffered from deep vein thrombosis in his left leg. Although platelet count decreases in patiens with ITP, platelet aggregation may increase. We must be aware of the possibility of the occurrence of venous thromboembolism.
　Jpn. J. Cardiovasc. Surg. 36: 180-183 (2007)

A Case of Refractory Sustained Ventricular Tachycardia with Dilated-Phase Hypertrophic Cardiomyopathy Treated by Left Ventriculotomy 　　K. Izumi, et al.……184

A Case of Refractory Sustained Ventricular Tachycardia with Dilated-Phase Hypertrophic Cardiomyopathy Treated by Left Ventriculotomy

(Division of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan)

Kenta Izumi Kiyoyuki Eishi Kouji Hashizume

Seiichi Tada Kentaro Yamane Hideaki Takai

Kazuyoshi Tanigawa Takashi Miura Shun Nakaji

A 63-year-old man had been receiving medical treatment for hypertrophic cardiomyopathy (HCM) for 20 years. Sustained ventricular tachycardia (VT) had often occurred over the previous 2 years in spite of the administration of antiarrhythmic drugs. He therefore received an implantable cardioverter defibrillator (ICD). However, his symptoms did not improve thus dilated-phase HCM was diagnosed. Because sustained VT often occurred subsequently, the ICD had to be frequently used. An electrophysiological study (EPS) using the CARTO electroanatomical mapping system revealed the earliest activation site to be in the posterolateral wall of the left ventricle (LV). VT did not stop despite 2 endocardial catheter ablation procedures. Therefore, the VT foci was thought to be a reentry circuit on the epicardial side of the posterolateral LV wall. A part of the posterolateral LV wall that involved the reentry circuit was therefore resected. Since undergoing this surgical procedure, the patient has experienced no recurrence of VT during a follow-up period of 14 months.
　Jpn. J. Cardiovasc. Surg. 36: 184-187 (2007)

Infective Endocarditis Followed by Fungal Prosthetic Valve Endocarditis and Mycotic Aneurysm of the Common Iliac Artery 　　K. Maruta, et al.……188

Infective Endocarditis Followed by Fungal Prosthetic Valve Endocarditis and Mycotic Aneurysm of the Common Iliac Artery

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

Kazuto Maruta Tadashi Omoto Noboru Ishikawa

Masanori Hirota Masaya Ohi Masaomi Fukuzumi

Masahiro Ohno Tadanori Kawada Takeo Tedoriya

A 44-year-old man with a history of remittent fever for 6 months was given a diagnosis of infective endocarditis of the aortic valve related to a congenital ventricular septal defect (VSD), although no bacterial growth was obtained by blood culture. After one week of antibiotic treatment, aortic valve replacement (AVR) and patch closure of the VSD were performed after debridement of infected tissue and vegetations involving the aortic root, pulmonary and tricuspid valves, and myocardium surrounding the VSD. Antibiotic treatment was continued postoperatively, but elevation of C-reactive protein (CRP) persisted. Blood culture disclosed Candida albicans in the blood 3 months after AVR. Fungal prosthetic valve endocarditis (PVE) was suspected, therefore, aortic root replacement with a Free Style bioprosthesis and VSD re-closure were performed followed by continued systemic antifungal treatment. Five months after reoperation, the patient was readmitted with a high fever. A pseudoaneurysm of the left common iliac artery and complete obstruction of the external iliac artery were shown by contrast-enhanced computed tomography (CT). The aneurysm was resected without revascularization. This case presentation concludes that long-term whole body study with contrast-enhanced CT might be necessary even though complete eradication of the infected foci of the heart has been established.
　Jpn. J. Cardiovasc. Surg. 36: 188-192 (2007)

Tricuspid Valve Replacement for a Patient with Corrected Congenital Transposition of the Great Vessels and Protein C Deficiency 　　G. Shinohara, et al.……193

Tricuspid Valve Replacement for a Patient with Corrected Congenital Transposition of the Great Vessels and Protein C Deficiency

(Department of Cardiovascular Surgery, Jikei University Hospital, Tokyo, Japan and Department of Cardiovascular Surgery, Saitama Children’s Medical Center*, Saitama, Japan)

Gen Shinohara* Kazuhiro Hashimoto Yoshimasa Sakamoto

Hiroshi Okuyama Makoto Hanai Takahiro Inoue

Ken Nakamura

Protein C (PC) deficiency is an inherited thrombotic disorder with a prevalence of 0.19% among the general population. PC deficiency is associated with an increased risk of thrombosis when other risk factors are present, such as trauma, surgery, or infection, and is an important cause of mechanical valve thrombosis. We performed tricuspid valve replacement with a 29mm Carpentier-Edwards Perimount valve in a 20-year-old man with PC deficiency. The patient had corrected transposition of the great vessels with severe tricuspid insufficiency, as well as a history of cerebral infarction. In the perioperative period, we used only heparin sodium as the anticoagulant. When we restarted administration of warfarin, changing over from heparin, transient increases of serum plasmin inhibitor-plasmin complex (PIC) and thrombin anti-thrombin complex (TAT) levels were observed. Despite an increased dose of heparin, an appropriate activated partial thromboplastin time (APTT) was not obtained. This suggested a hypercoagulatory state, but the postoperative course was uneventful. Management of perioperative anticoagulation, prevention of late thrombotic events, and prosthetic valve selection in this particular situation are discussed.
　Jpn. J. Cardiovasc. Surg. 36: 193-197 (2007)

A Case of Stent-Graft Occlusion 5 Years after Endovascular Repair for Abdominal Aortic Aneurysm 　　K. Ataka, et al.……198

A Case of Stent-Graft Occlusion 5 Years after Endovascular Repair for Abdominal Aortic Aneurysm

(Department of Cardiovascular Surgery, Sumitomo Hospital, Osaka, Japan and Department of Thoracic and Cardiovascular Surgery, Saiseikai Nakatsu Hospital*, Osaka, Japan)

Keiji Ataka Masahiro Sakata Takashi Munezane

Kazuhiko Iwahashi*

A 75-year-old man was admitted complaining of sudden bilateral foot coldness and numbness. The patient had undergone endovascular repair for abdominal aortic aneurysm (AAA) 5 years previously. Abdominal X-ray showed a highly kinked endovascular stent-graft, and aortography revealed occlusion of the stent-graft and infrarenal aorta. Emergency axillo-bifemoral bypass was performed to restore the blood flow of the lower extremities, and he recovered uneventfully. Endovascular repair for AAA can be performed with low mortality and morbidity, and is accepted worldwide as a minimally invasive treatment. However, there are several late complications, such as newly developed endoleak, graft migration, graft occlusion, AAA expansion, and AAA rupture. Therefore, great attention should be paid to following patients treated with endovascular procedures for abdominal aortic aneurysm.
　Jpn. J. Cardiovasc. Surg. 36: 198-201 (2007)

A Case of Coral Reef Aorta Causing Blue Toe Syndrome 　　K. Maeda, et al.……202

A Case of Coral Reef Aorta Causing Blue Toe Syndrome

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

Koji Maeda Naoki Toya Kenjiro Kaneko

Koji Kurosawa Yuka Negishi Yuji Kanaoka

Takao Ohki

A 53-year-old man presented with a painful, non-healing ischemic ulcer of the left fifth toe. The patient was initially treated conservatively for 4 months with local debridement and medication with antiplatelet therapy but his symptoms and the ulcer was refractory. A computed tomography revealed a bulky, irregular, gritty, localized calcification of the infra-renal aorta and was compatible with the so-called “coral reef aorta”. Angiography confirmed the findings of the CT scan, and there was no evidence of occlusive lesions in the distal runoff vessels. A diagnosis of blue toe syndrome secondary to infra-renal coral reef aorta was made. In order to prevent further embolization, the patient underwent aortic excision with PTFE grafting via a retro-peritoneal incision. In order to increase the microcirculation of the toe and to aid in the healing of the ulcer, a lumbar sympathectomy was performed simultaneously. The ulcer healed completely on postoperative day 47. The treatment method for coral reef aorta depends on the presence or absence of global ischemia of the lower extremity and embolic complications.
　Jpn. J. Cardiovasc. Surg. 36: 202-205 (2007)

A Case of Heparin-Induced Thrombocytopenia following Surgery for DeBakey Type I Acute Aortic Dissection 　　H. Kunishige, et al.……206

A Case of Heparin-Induced Thrombocytopenia following Surgery for DeBakey Type I Acute Aortic Dissection

(Division of Cardiovascular Surgery, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan)

Hideyuki Kunishige Kazuhiro Myojin Yoshimitsu Ishibashi

Koji Ishii Junichi Oka

A 73-year-old man underwent ascending aortic replacement and F-F crossover bypass for acute aortic dissection with right leg ischemia. He was treated postoperatively for acute renal failure due to myonephropathic metabolic syndrome (MNMS) with continuous hemodiafiltration. He suffered from acute graft occlusion and brain infarction on postoperative day (POD) 3. Although recovery of organ functions was observed, an unexpected decrease in platelet count occurred rapidly below 1.1×10⁴/μl on POD 6. We suspected heparin-induced thrombocytopenia (HIT) and all heparin administration was halted and argatroban was initiated at a dose of 0.2μg/kg/min, with titration to achieve an activated partial thromboplastin time (APTT) of 1.5-3.0 times the initial value not to exceed 100 sec. The platelet factor 4-reactive HIT antibody was positive and definite diagnosed of HIT was made. Administration of warfarin started after the platelet count recovered to 10.0×10⁴/μl on POD 36. Awareness of the clinical features and different presentations of HIT are essential for preventing severe complications associated with this disease.
　Jpn. J. Cardiovasc. Surg. 36: 206-210 (2007)

A Surgical Repair of Aneurysm of the Sinus of Valsalva Dissecting into the Interventricular Septum 　　Y. Ohkawa……211

A Surgical Repair of Aneurysm of the Sinus of Valsalva Dissecting into the Interventricular Septum

(Department of Cardiovascular Surgery, Hokushinkai Megumino Hospital, Eniwa, Japan)

Youhei Ohkawa

A44-year-old woman received pacemaker implantation (PMI) at age 43 because of complete atrioventricular block. One year after PMI, she suffered palpitations and fainting. Cardiac examination revealed aneurysm of the sinus of Valsalva dissecting into the interventricular septum and severe aortic regurgitation. Patch closure of the aneurysm of the sinus of Valsalva and aortic valve replacement were carried out under complete cardiopulmonary bypass. The endocardial leads were removed and epicardial leads were implanted for the pacemaker. This is a very rare case. The first symptom could have developed from conduction disturbance, such a complete atrioventricular block. The patch closure of the aneurysm and aortic valve replacement was considered effective for this disease.
　Jpn. J. Cardiovasc. Surg. 36: 211-214 (2007)

Acute Aortic Dissection Occurring on the Day after Coronary Artery Bypass Operation 　　K. Nakamura, et al.……215

Acute Aortic Dissection Occurring on the Day after Coronary Artery Bypass Operation

(Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Matsudo, Japan)

Koki Nakamura Yuji Suda Yosuke Saito

Mikiko Murakami Tomohiro Asai Hiroki Yamaguchi

A 73-year-old woman was referred to our hospital for angina pectoris due to triple-vessel-disease. She underwent off-pump coronary artery bypass grafting ×3 (RITA-LAD, LITA-OM, SV-PDA). Her vital signs were stable during the operation and the postoperative status was steady in the ICU. However, on the next day, she suddenly had severe back pain with markedly elevated blood pressure. Urine output immediately shut down and respiratory failure progressed with time. An enhanced CT scan revealed aortic dissection (DeBakey type I and Stanford type A). An emergency operation was performed via re-sternotomy. Cardiopulmonary bypass was initiated and the body was cooled down to 20℃. Under circulatory arrest with isolated cerebral perfusion, the ascending aorta was replaced using a one-branched Hemashield graft (26mm in diameter). The entry of the dissection was located at the proximal anastomosis site of the vein graft. The postoperative course was uneventful and she was discharged on the 24th postoperative day.
　Jpn. J. Cardiovasc. Surg. 36: 215-217 (2007)

Distal Arch Replacement for Intrathoracic Left Subclavian Artery Aneurysmin a 68-Year-Old Man 　　K. Nakamura, et al.……218

Distal Arch Replacement for Intrathoracic Left Subclavian Artery Aneurysm in a 68-Year-Old Man

(Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Matsudo, Japan)

Koki Nakamura Mikiko Murakami Tomohiro Asai

Yosuke Saito Yuji Suda Hiroki Yamaguchi

A 68-year-old man was referred to our hospital with an abnormal shadow on chest X-ray film. Enhanced chest CT scan revealed intrathoracic left subclavian artery aneurysm（maximum diameter 4cm) just above the aortic arch. Surgery was indicated considering the risks of aneurysm rupture and distal embolism, although he was asymptomatic. Under left 4th posterolateral thoracotomy, the aneurysm was exposed. Cardiopulmonary bypass was initiated with cannulation of the left femoral artery and vein (to the right atrium). Circulatory arrest and isolated cerebral perfusion were achieved at 25℃ core-temperature. The distal arch was replaced using a 26mm Hemashield graft and the left subclavian artery was reconstructed interposing an 8mm graft. The postoperative course was uneventful: he was extubated at 8h and was sent to the ward the next day. He was given an ambulatory discharge on the 13th postoperative day.
　Jpn. J. Cardiovasc. Surg. 36: 218-220 (2007)

Reconstructing a Coronary Artery Bypass Graft of an Ascending Aorta after an Acute Type I Aortic Dissection 　　R. Asano, et al.……221

Reconstructing a Coronary Artery Bypass Graft of an Ascending Aorta after an Acute Type Ⅰ Aortic Dissection

(Department of Cardiovascular Surgery, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan)

Ryota Asano Kojiro Kodera Yuji Suda

Akihito Sasaki Masahiro Ikeda Go Kataoka

Yasuo Takeuchi

A 50-year-old man who had coronary artery bypass grafting (LITA-LAD, RA-RCA, SVG-OM-PL) 6 years previously was admitted with acute dissection of the aorta (DeBakey type Ⅰ). Preoperative computed tomography showed that all coronary bypass grafts were patent. We replaced the graft of the ascending aorta and reconstructed the coronary artery bypass by re-sternotomy, circulatory arrest (rectal temperature: 23.6℃), retrograde cerebral perfusion, and intermittent retrograde cardioplegia. Because a radial artery (RA) graft and a saphenous vein graft (SVG) each had intact orifices, we detached them together and attached the grafts back to the aortic graft wall. He was weaned successfully from cardiopulmonary bypass without difficulty and postoperative transthoracic echocardiography (TTE) showed good left ventricle (LV) function. Postoperative multidetector-row computed tomography (MDCT) showed that the RA graft and SVG were patent. By performing circulatory arrest and intermittent retrograde cardioplegia, we successfully protected the myocardial function of a patient with acute aorta dissection after a CABG and we reconstructed the graft without needing further coronary anastomosis.
　Jpn. J. Cardiovasc. Surg. 36: 221-224 (2007)

Clinical Study of Nine Cases of Extraanatomic Bypass from the Thoracic Aorta to Bifemoral Arteries 　　A. Sasaki, et al.……225

Clinical Study of Nine Cases of Extraanatomic Bypass from the Thoracic Aorta to Bifemoral Arteries

(Department of Cardiovascular Surgery, Sunagawa Medical Center, Sunagawa, Japan)

Akihiko Sasaki Shinji Nakashima Akira Fujii

Masahiro Miyajima

We performed extraanatomic bypass from the thoracic aorta to bifemoral arteries for 4 aortoiliac occlusive disease (AIOD) patients (including 2 dialysis patients) with severe calcification of abdominal aorta and 5 high aortic occlusion (HAO) patients between January 2001 and September 2006. The average age was 69 years old (range 46-80) including 6 men. Two HAO cases were in the acute phase, one of whom had accompanying lower limb paralysis. Two of the AIOD cases showed small aorta syndrome. The mean operation time was 145 min and intra- or postoperative bleeding was very low. We lost one peritoneal dialysis patient with AIOD in the 2nd postoperative week, due to infection from the CAPD tube. Perigraft seroma which is a complication of the artificial blood vessel itself was seen in 3 patients but graft patency was 100 percent at 2 years postoperatively.
　Jpn. J. Cardiovasc. Surg. 36: 225-227 (2007)

Successful Treatment of an Aortoesophageal Fistula after Open Stent Grafting of a Right Aortic Arch and a Descending Aortic Aneurysm Rupture 　　M. Nishimoto, et al.……228

Successful Treatment of an Aortoesophageal Fistula after Open Stent Grafting of a Right Aortic Arch and a Descending Aortic Aneurysm Rupture

(Department of Thoracic and Cardiovascular Surgery, Osaka Mishima Emergency and Critical Care Medical Center, Takatsuki, Japan)

Masayoshi Nishimoto Takao Tsuchida Hiroshi Akimoto

Fuyo Tsukiyama Kan Hamori Hitoshi Fukumoto

A 52-year-old man suffered from rupture of a right aortic arch and a descending aortic aneurysm. The patient was treated with an open stent grafting technique, and complete revascularization was achieved. Twelve days after the operation, a computed tomographic scan revealed a fistula between the distal esophagus and the excluded aneurysm sac. Twenty-six days later, the patient was treated by an esophagectomy, a cervical esophagogastrostomy, as well as a feeding jejunostomy. The infectious parietal thrombus was partially debrided, and the aneurysm sac was filled with omentum. The patient recovered uneventfully. The patient has been followed for 18 months with no signs of infection.
　Jpn. J. Cardiovasc. Surg. 36: 228-232 (2007)

A Case of Endovascular Aortic Repair of Traumatic Thoracic Aortic Rupture 　　H. Midorikawa, et al.……233

A Case of Endovascular Aortic Repair of Traumatic Thoracic Aortic Rupture

(Department of Cardiovascular Surgery, Southern Tohoku General Hospital, Koriyama, Japan)

Hirofumi Midorikawa Megumu Kanno Kazunori Ishikawa

Shigehiro Morishima Takashi Ono

A 54-year-old man, involved in a motor vehicle collision, was transferred to our hospital. He was hemodynamically stable. A CT scan of the chest demonstrated traumatic aortic dissection and a mediastinal hematoma with hemothorax of left side. Endovascular aortic repair using a homemade device was immediately performed, and a completion angiogram revealed complete exclusion of the aortic injury, with no extravasation. A postoperative CT scan revealed satisfactory placement of the endograft, with no extravasation. The patient was discharged on the 13th postoperative day. Endovascular aortic repair was useful and minimally invasive therapy in this case for the treatment of traumatic thoracic aortic rupture.
　Jpn. J. Cardiovasc. Surg. 36: 233-236 (2007)