Japanese Journal of Cardiovascular Surgery Vol.36, No.5

Originals

  • Improving Outcomes in Right Atrial Isomerism   T. Nakata, et al.……237
    Improving Outcomes in Right Atrial Isomerism

    (Department of Cardiovascular Surgery, Shizuoka Children’s Hospital, Shizuoka, Japan)

    Tomohiro Nakata Akio Ikai Yoshifumi Fujimoto
    Keiichi Hirose Noritaka Ota Yuko Tosaka
    Yujiro Ide Kisaburo Sakamoto
    Surgery for right atrial isomerism usually has a poor outcome because of complex congenital cardiac malformations. Here we rearn the outcomes of all 71 consecutive patients with right atrial isomerism whom we treated from their initial operation at Shizuoka Children’s Hospital between January 1987 and October 2006. We categorized 34 patients treated between 1987 and 1996 as the ‘early’ group, and 37 patients between 1997 and 2006 as the ‘late’ group. The early group was more commonly associated with pulmonary stenosis (p=0.010), and the late group was more commonly associated with neonatal status (p=0.010), body weight less than 3.0kg (p=0.037), and pulmonary atresia (p=0.013). All 71 patients were scheduled for single ventricular repair. Survival in the early group was 52.9% at 1 year, and 32.4% at 5 years, and this poor outcome was related to 2 factors; cardiac dysfunction from volume loading and inappropriate lung perfusion area for Fontan completion. We therefore changed our surgical strategy in the late group as follows: earlier right heart bypass operation and aggressive atrioventricular valvoplasty to prevent volume overloading, and central pulmonary artery (PA) strategy (central PA plasty and blood flow source anastomosed to the central PA) and improvement of anastomosis of total anomalous pulmonary venous connection (TAPVC) to preserve appropriate lung perfusion area. If severe unbalanced pulmonary blood flow occurred, it was treated with a novel surgical approach consisting of ‘intrapulmonary-artery septation’. Survival in the late group was 66.8% at 1 year, and 53.1% at 5 years, which was better than the early group, but not with statistical significance (p=0.102). Univariate analysis identified significant risk factors for mortality as neonatal status (p=0.036), extracardiac TAPVC (p=0.049), and preoperative pulmonary vein obstruction (PVO) (p=0.001) in the early group, and mixed TAPVC (p=0.001) in the late group. Multivariate analysis identified preoperative PVO (p=0.038) in the early group, and mixed TAPVC (p=0.007) in the late group as significant risk factors for mortality. Outcome is improving with our current strategy of preventing volume overloading and preserving an appropriate lung perfusion area, even in the late group with more severe cases, and neonatal status, extracardiac TAPVC, and preoperative PVO are no longer risk factors for mortality, but mixed type TAPVC remains a serious problem and is associated with high mortality.
     Jpn. J. Cardiovasc. Surg. 36: 237-244 (2007)
  • The Long-Term Results of Left Internal Thoracic Artery Grafting in the Left Anterior  Descending Artery with Either a Sternotomy or an Anterior Minithoracotomy   H. Iwahashi, et al.……245
    The Long-Term Results of Left Internal Thoracic Artery Grafting in the Left Anterior Descending Artery with Either a Sternotomy or an Anterior Minithoracotomy

    (Department of Cardiovascular Surgery, Fukuoka University, School of Medicine, Fukuoka, Japan)

    Hidehiko Iwahashi Tadashi Tashiro Noritugu Morishige
    Yoshio Hayashida Nobuhisa Ito Kazuma Takeuchi
    Hideki Teshima Go Kuwahara
    The main objective of this study was to describe the long-term results of left internal thoracic artery grafting of the left anterior descending artery with a sternotomy or anterior minithoracotomy without using extracorporeal circulation. From March 1997 to February 2000, a median sternotomy was performed in 8 patients and a minithoracotomy in 22 patients. We compared and analyzed the findings of these groups. An emergency operation was performed in 75% of the patients in the median sternotomy group and in 27.3% of those in the minithoracotomy group (p=0.03). The operation time was 2.1h in the median sternotomy group and 3.9h in the minithoracotomy group (p<0.01). The early graft patency rate was 100% in the median sternotomy group and 90.4% in the minithoracotomy group (NS). The five-year actuarial survival rate was 100% in the median sternotomy group and 86.4% in the minithoracotomy group. The five-year cardiac event free rate was 100% in the median sternotomy group and 86.4% in the minithoracotomy group. In conclusion, the results for the median sternotomy group were comparatively better than for minithoracotomy group. Minithoracotomy and median sternotomy have differences in operation time, early graft patency and early outcome. The median sternotomy technique therefore remains an invaluable operative modality for the treatment of one-vessel disease.
     Jpn. J. Cardiovasc. Surg. 36: 245-247 (2007)
  • Surgical Removal of Left Ventricular Ball-Like Thrombus   H. Minami, et al.……248
    Surgical Removal of Left Ventricular Ball-Like Thrombus

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

    Hiroya Minami Tatsuro Asada Kunio Gan
    Takashi Munezane
    Left ventricular (LV) thrombus is an uncommon primary disease, but following acute myocardial infarction (AMI) it is a common complication associated with a risk of systemic embolism. Especially if the thrombus is ball-shaped, there is a higher risk of systemic embolism. We reviewed 4 cases of thrombectomy including 1 with the acute phase of AMI and another with Takotsubo disease. Between January 2000 and August 2005, 4 consecutive patients underwent thrombectomy for ball-like thrombus in the left ventricle (all men, mean age 53.5 years). We performed thrombectomy through left ventriculotomy. In 3 patients ventriculotomy was repaired with direct closure with double PTFE felt reinforcement, and in the other large acute AMI with the infarction exclusion technique (Komeda-David) because the LV wall was remarkably fragile. All thrombi were ball-like and fresh (mean size 15.8mm). Concomitant coronary artery bypass grafting was performed in 3 cases, the Maze procedure in 2, and mitral annuloplasty (MAP) in 1. All patients survived and have been doing well without any major complications. Surgical thrombectomy is safe and can improve prognosis without systemic embolism. In the acute phase of AMI, the infarction exclusion technique is excellent to prevent bleeding and postoperative remodeling of the left ventricular wall.
     Jpn. J. Cardiovasc. Surg. 36: 248-252 (2007)
  • Clinical Experience with Terumo Large Diameter Graft (Triplex®)   S. Takamoto, et al.……253
    Clinical Experience with Terumo Large Diameter Graft (Triplex®)―Results of a Multicenter Clinical Trial―

    (Cardiothoracic Surgery, The University of Tokyo Hospital1), Cardiovascular Surgery, Hokkaido University Hospital (Now: Sapporo Medical Center NTT EC)2), Cardiovascular Surgery, Tohoku University Hospital3), Cardiovascular Surgery, Saitama Medical School Hospital4), Surgery, Saitama Medical Center5), Vascular Surgery, The University of Tokyo Hospital6), First Department of Surgery, Hamamatsu University School of Medicine7), Cardiovascular Surgery, National Cardiovascular Center8), Surgery, Kurume University Hospital9) and Surgery, Saga Medical School Hospital10))

    Shinichi Takamoto1) Keishu Yasuda2) Koichi Tabayashi3)
    Shun-ei Kyo4,5) Tetsurou Miyata6) Teruhisa Kazui7)
    Toshikatsu Yagihara8) Shigeaki Aoyagi9) Tsuyoshi Itoh10)
    We conducted a clinical study on a newly developed large diameter vascular graft (Triplex®, Terumo Corporation, Tokyo, Japan) with a non-biodegradable material used as sealing material, to evaluate its effectiveness and safety. Triplex® grafts were implanted in 170 patients with either aneurysmal or occlusive arterial disease in either the thoracic artery, abdominal artery or iliac arteries, between October 2001 and March 2003. The patients consisted of 141 men and 29 women with an average age of 69.0±10.0 years old (mean±SD). In 82 patients, Triplex® was implanted for the thoracic artery area, in 88, for the abdominal artery area. The cumulative graft patency rate 12 months after implantation was 100.0% in each area, there was no any abnormality such as occlusion or rupture from the trunk of Triplex®. The distension ratio, which is the index of the dilatation resistance, was 1.03±0.06 as a whole (n=139), 1.03±0.06 in the thoracic artery area (n=73), 1.03±0.06 in the abdominal artery area (n=66). In other words the dilatation of Triplex® was hardly observed. As manipulability during the operation, the following characteristics were evaluated; anastomosis, resistance to fraying, hemorrhage, conformability with the host vessel. Triplex® was evaluated as “good” in 75% of all items accounted for 75% or more. A transitory rise thought to be due to the surgical stress immediately after the operation because of the change of temperature and laboratory findings (CRP, WBC) between implantation and discharge was observed, but then recovered to the normal levels of each patients at discharge and the re-elevation was not recognized. In 90 patients, 277 adverse events occurred. Although in 33 adverse events in 21 patients a causal relation with Triplex® could not be excluded, most of them were already known events as complications which could occur after operation on the aorta. Therefore, it was confirmed that Triplex® has certain advantages: 1) good manipulability, 2) good patency and dilatation resistance, 3) no inflammatory reaction related to Triplex®, as a graft for the aorta.
     Jpn. J. Cardiovasc. Surg. 36: 253-260 (2007)

Case Reports

  • A Resected Case of Biventricular Thrombi with Cardiac Sarcoidosis   I. Kitazono, et al.……261
    A Resected Case of Biventricular Thrombi with Cardiac Sarcoidosis

    (Department of Cardiovascular Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan)

    Iwao Kitazono Masafumi Yamashita Hiroyuki Motodaka
    Ryuuji Iwashita Takayuki Ueno Yoshihiro Fukumoto
    Goichi Yotsumoto Hitoshi Toyohira
    A 59-year-old woman with a history of pulmonary and cardiac sarcoidosis was admitted to our hospital because of acute femoral artery occlusive diseases. Preoperative echocardiography showed diffuse hypokinesis and biventricular tumors. Transesophageal echocardiography revaealed mobile biventricular tumors. The tumors which consisted of organized thrombi were successfully excised. She was discharged 23 days after surgery. This suggested that hypokinesis accompanying cardiac sarcoidosis caused the biventricular thrombi.
     Jpn. J. Cardiovasc. Surg. 36: 261-264 (2007)
  • Two Cases of Successful Treatment of Tracheo-Innominate Artery Fistula   H. Yoshida, et al.……265
    Two Cases of Successful Treatment of Tracheo-Innominate Artery Fistula

    (Department of Cardiovascular Surgery, Kagawa Children’s Hospital, Zentsuji, Japan)

    Homare Yoshida Yoshiyasu Egawa Tomohisa Kawahito
    Tracheo-innominate artery fistula (TIF) is a relatively rare, highly lethal complication after tracheostomy. We report two cases of successfully managed TIF with relatively long-term survival after a massive hemorrhage from the tracheostomy site. Different approaches were employed for the temporary control of bleeding and in the subsequent surgery in these two cases, thus we examined the pros and cons of each approach. In Case 1, the bleeding was temporarily controlled using a long tracheostomy tube and orotracheal tube and by applying digital compression to the tracheostomy site. The right common iliac-to-right axillary artery bypass was then performed, followed by a median sternotomy to resect the injured innominate artery and to directly close the tracheal fistula. In Case 2, an over-inflated cuff was used after inserting the long tracheostomy tube to its full extent from the tracheostomy site, which was able to stop the bleeding for a while. This resulted in massive rebleeding when the cuff was remored while the patient was being transferred to the operation room. The patient underwent median sternotomy followed by anatomic innominate artery reconstruction using an ePTFE graft, and closure of the tracheal fistula was performed using autologous pericardium patch. In the treatment of TIF, prevention must be the greatest priority. If premonitory bleeding occurs (in the form of minor fresh bleeding), the patient must be evaluated immediately using bronchoscopy and CT imaging, and surgical intervention should be considered depending on the condition. If the bleeding is severe, the airway should be maintained and the bleeding should be temporarily controlled. We were able to control the bleeding in Case 1; however, in Case 2, we were unable to so since the tracheostomy tube was not long enough. After the surgery, we thought that the outcome might have been different if we had used the orotracheal tube instead of the tracheostomy tube and we believe this is one point that should be carefully considered. As for the procedures chosen for the TIF surgeries, anatomic revascularization of the innominate artery and closing the tracheal fistula are the procedures of choice when the operation field is not contaminated. However, when the field is contaminated (for example, in the case of a large fistula), extra-anatomic revascularization may be the only choice. This indicates that early evaluation and intervention of TIF are also important in terms of preventing infections and long-term prognosis.
     Jpn. J. Cardiovasc. Surg. 36: 265-268 (2007)
  • A Case of Blow-Out Type Cardiac Rupture after Acute Myocardial Infarction   M. Goda, et al.……269
    A Case of Blow-Out Type Cardiac Rupture after Acute Myocardial Infarction

    (Division of Cardiovascular Surgery, Yokohama City University Medical Center, Yokohama, Japan)

    Motohiko Goda Kiyotaka Imoto Shinichi Suzuki
    Keiji Uchida Kensuke Kobayashi Koichiro Date
    Toshiki Hatsune Makoto Okiyama Makoto Kato
    A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.
     Jpn. J. Cardiovasc. Surg. 36: 269-272 (2007)
  • A Case of Horner’s Syndrome after Coronary Artery Bypass Graft Surgery   T. Murakami, et al.……273
    A Case of Horner’s Syndrome after Coronary Artery Bypass Graft Surgery

    (Department of Cardiovascular Surgery, Oji General Hospital, Tomakomai, Japan)

    Tatsuya Murakami Hiroki Kato Yutaka Makino
    Horner’s syndrome is a rare complication after open heart surgery via median sternotomy. To date only two cases have been reported in Japan. A 77-year-old woman presented to our hospital, complaining of worsening effort angina. She was found to have old inferior myocardial infarction, severe triple vessel diseases and ischemic mitral regurgitation. At operation, the patient was placed in the supine position with the left arm abducted to approximately 80 degrees to harvest the left radial artery. At the same time, the left internal thoracic artery was dissected free from the chest wall using a Delacroix-Chevalier retractor following median sternotomy. She underwent mitral ring annuloplasty and three coronary artery bypass graftings on cardiopulmonary bypass. Her immediate postoperative course was uneventful. On postoperative day (POD) 2, however, left Horner’s syndrome became apparent with the classical triad: ptosis, miosis and enophthalmos. She subsequently complained of pain and numbness of the left arm. A chest X-ray film on POD 4 revealed posterior fracture of the left first rib, suggesting that the fracture fragments or the associated hematoma could have caused direct injury of the cervical sympathetic trunk and the brachial plexus. On POD 21, the discharge day, the neurological symptoms still persisted mildly but spontaneously resolved within 6 months. In order to prevent such complications, we should treat the sternum and the ribs with great caution when using a sternal retractor and harvesting the internal thoracic arteries.
     Jpn. J. Cardiovasc. Surg. 36: 273-276 (2007)
  • A Surgical Case of Trapped Thrombus in a Patent Foramen Ovale with  Suspicion of Paradoxical Embolism   K. Iwahashi, et al.……277
    A Surgical Case of Trapped Thrombus in a Patent Foramen Ovale with Suspicion of Paradoxical Embolism

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

    Kazuhiko Iwahashi Tomoaki Iwasaki Hirofumi Kanda
    Keiji Ataka*
    A 78-year-old woman complaining of suddenly developed numbness and coldness of the left hand was referred to our hospital on the suspicion of embolism. A 2×1cm mass was revealed in the fossa ovalis of the interatrial septum by echocardiography. She underwent operation under a preoperative diagnosis of thrombus in the left atrium or tumor of the interatrial septum. In the operation, the mass was excised including the interatrial septum and the defect of the interatrial septum was closed with a PTFE patch. A sagittal section of the mass showed that it was a fresh thrombus covered with normal endocardium of the fossa ovalis except for a small protrusion to the left atrial cavity. These findings yielded diagnosis of thrombus trapped in a patent foramen ovale. She was discharged after an uneventful postoperative course, although temporary pacing was needed for transient bradycardia in the early postoperative days. In this case, we hypothesize that an unidentified venous thrombus trapped in a patent foramen ovale had partly passed through the interatrial septum and caused paradoxical embolism in the left hand. Paradoxical embolism is a well-known phenomenon described in a number of reports. There are some reports of a trapped thrombus in a patent foramen ovale detected by echocardiography or in autopsy. We describe a rare case of surgical demonstration of a trapped thrombus in a patent foramen ovale, and recommend that examinations for venous thrombus with a suspicion of paradoxical embolism are necessary for patients of thromboembolism.
     Jpn. J. Cardiovasc. Surg. 36: 277-280 (2007)
  • Sealed Rupture of an Internal Iliac Artery Aneurysm in a 92-Year-Old Woman  Surgically Treated with Success   K. Nakamura, et al.……281
    Sealed Rupture of an Internal Iliac Artery Aneurysm in a 92-Year-Old Woman Surgically Treated with Success

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

    Koki Nakamura Tomohiro Asai Mikiko Murakami
    Yosuke Saito Yuji Suda Hiroki Yamaguchi
    A 92-year-old woman was referred to our hospital with lower abdominal pain and lumbago. Her vital signs were stable at an emergency outpatient-clinic. An enhanced CT scan showed a sealed rupture of a right internal iliac artery aneurysm (85×73mm in diameter). An emergency operation was performed via median laparotomy. As predicted pre-operatively, a large hematoma was found in the retroperitoneal space and mesenterium surrounding the right internal iliac artery aneurysm (sealed rupture). Y-grafting was performed using a 16×8mm Intergard: proximal and distal ends of the graft were the abdominal aorta and bilateral femoral arteries, respectively. Left common iliac artery, right external iliac artery and right internal arterial aneurysm were suture-closed. The postoperative course was uneventful and she was discharged on the 13th postoperative day on foot.
     Jpn. J. Cardiovasc. Surg. 36: 281-283 (2007)
  • Damus-Kaye-Stansel Anastomosis for Rapid Progression of Subaortic Stenosis after  Pulmonary Artery Banding in a Single Ventricle Infant with Aortic Arch Hypoplasia   H. Kato, et al.……284
    Damus-Kaye-Stansel Anastomosis for Rapid Progression of Subaortic Stenosis after Pulmonary Artery Banding in a Single Ventricle Infant with Aortic Arch Hypoplasia

    (Department of Cardiovascular Surgery, Tsukuba University Hospital, Tsukuba, Japan and Department of Cardiovascular Surgery, Ibaraki Children’s Hospital*, Mito, Japan)

    Hideyuki Kato Yuji Hiramatsu Yukiko Ban
    Mio Noma Shinya Kanemoto* Masakazu Abe*
    Yuzuru Sakakibara
    A cyanotic baby boy was given a diagnosis of single right ventricle, double outlet right ventricle, hypoplastic aortic arch, mitral atresia, atrial septal defect and pulmonary-ductus-descending aorta trunk. On day 4, extended aortic arch anastomosis and pulmonary artery banding were undertaken. At age 70 days, severe cyanosis and respiratory distress appeared and advanced rapidly. Angiography revealed critical subaortic stenosis and pulmonary hypertension, and the patient required urgent Damus-Kaye-Stansel anastomosis with concomitant right modified Blalock-Taussig shunt. Patients with single ventricle and hypoplastic aortic arch are a high-risk subgroup of progressive subaortic stenosis after initial pulmonary artery banding, and therefore need careful observation and may require early relief of subaortic stenosis.
     Jpn. J. Cardiovasc. Surg. 36: 284-287 (2007)
  • A Case Report of Bidirectional Glenn Shunt as a Therapeutic Aid in an Urgent  Operation for Active Tricuspid Valve Endocarditis   I. Kawase and M. Kawada……288
    A Case Report of Bidirectional Glenn Shunt as a Therapeutic Aid in an Urgent Operation for Active Tricuspid Valve Endocarditis

    (Department of Cardiovascular Surgery, Mie Heart Center, Mie, Japan and Division of Cardiovascular Surgery, Jichi Medical University*, Shimotsuke, Japan)

    Isamu Kawase Masaaki Kawada*
    We had the opportunity to use a bidirectional Glenn shunt (BDG) as a therapeutic aid in an urgent operation of active tricuspid valve endocarditis in an adult case with the tetralogy of Fallot. The patient was a 44-year-old man with untreated tetralogy of Fallot. He noticed progressing dyspnea on exertion and chest discomfort a few years previously. He had suffered from fever and cough during these several months. At last he was admitted to our Center on an emergency basis due to persistent high fever. Echocardiography revealed large vegetation on the tricuspid valve along with positive blood culture of Streptococcus. Antibiotic therapy was started, but septic lung embolism forced us to perform an urgent operation. To avoid using an artificial valve or leaving free tricuspid regurgitation with tricuspid valve excision, we repaired the tricuspid valve using fresh autologous pericardium and DeVega annuloplasty. Since we left stenosis at tricuspid valve, we added the BDG to minimize the volume load on the repaired tricuspid valve. It worked well and the patient successfully was weaned from CPB. Despite the initial postoperative course related to the lung abscess from the infected embolism, the patient is doing well at home 12 months after the surgery. This strategy using BDG is one modalilty to cope with this formidable situation.
     Jpn. J. Cardiovasc. Surg. 36: 288-291 (2007)
  • An Alternative Method for Enlargement of Left Atrioventricular Valvular Annulus at  Repeat Prosthetic Valve Replacement in Atrioventricular Septal Defect   T. Kawahito, et al.……292
    An Alternative Method for Enlargement of Left Atrioventricular Valvular Annulus at Repeat Prosthetic Valve Replacement in Atrioventricular Septal Defect

    (Department of Cardiovascular Surgery, National Hospital Organization, Kagawa Children’s Hospital, Zentsuji, Japan)

    Tomohisa Kawahito Takashi Tominaga Yoshiyasu Egawa
    A 10-year-old girl was given a diagnosis of mitral stenosis due to a small prosthetic valve. She had undergone intra-cardiac repair operations for a complete atrioventricular septal defect by a two-patch method at 6 months after birth, and for left atrioventricular valve insufficiency by replacement with a mechanical prosthesis (SJM-HP-17mm) at 2 years of age. The cause of mitral stenosis was considered to be that the existing prosthesis was too small for her body growth. Reoperation was done with a trans-septal approach, but despite the resection of the old prosthesis and peripheral fibrous tissue her left atrioventricular annulus was not big enough to insert a larger prosthesis. We thus cut the previous VSD patch about 1cm toward the apex, and sutured a patch for annular enlargement. After this annular enlargement, we could insert a larger prosthesis (SJM-HP-21mm). Her postoperative course was uneventful. There was no left ventricular outflow obstruction and no worsening of her mild right atrioventricular regurgitation. There are few established procedures for enlargement of a left atrioventricular annulus. Our method presented here is safe and effective for left atrioventricular annular enlargement, but can only be applied to patients with atrioventricular septal defect.
     Jpn. J. Cardiovasc. Surg. 36: 292-294 (2007)
  • Off-Pump Coronary Artery Bypass Grafting in a Patient with Giant Gastric Varices   N. Karube and M. Mo……295
    Off-Pump Coronary Artery Bypass Grafting in a Patient with Giant Gastric Varices

    (Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan and Department of Cardiovascular Surgery, Saiseikai Yokohama City Nanbu Hospital*, Yokohama, Japan)

    Norihisa Karube* Makoto Mo
    A 79-year-old woman with angina pectoris was admitted to our institution. Coronary angiography revealed triple vessel disease. The patient had giant gastric varices 30mm in diameter and also had liver cirrhosis (Child-Pugh classification grade A). To prevent perioperative bleeding complications, we selected and performed off-pump coronary artery bypass grafting (RITA-LAD#8, LITA-LCx#14, Ao-RA-#4AV). She was discharged on the 12th postoperative day without any complications.
     Jpn. J. Cardiovasc. Surg. 36: 295-297 (2007)
  • Ruptured Mycotic Aneurysm of the Deep Femoral Artery Associated with  Infective Endocarditis   T. Nakanishi and T. Mizuno……298
    Ruptured Mycotic Aneurysm of the Deep Femoral Artery Associated with Infective Endocarditis

    (Department of Cardiovascular Surgery, Machida Municipal Hospital, Machida, Japan)

    Tomoyuki Nakanishi Tomohiro Mizuno
    We report a rare case of a ruptured mycotic aneurysm (MA) of the deep femoral artery (DFA) associated with infective endocarditis (IE). A 59-year-old woman was referred to our hospital with acute IE. Six days after anti-bacterial therapy, she complained of sudden pain in her right thigh. This condition was diagnosed as a bacterial thrombus in the right DFA. Three weeks after valve replacement, she again complained of pain and swelling of her right thigh. CT angiography revealed a ruptured MA of the right DFA. Since the infection was completely controlled at that time, we only ligated the proximal right DFA to attain hemostasis and did not attempt excision of the MA. However, because signs of recurrent infection appeared to slightly increase after surgery, we completely excised the MA to prevent infection of the prosthetic valves. Thus far, there is no evidence of recurrent aneurysm formation and infection.
     Jpn. J. Cardiovasc. Surg. 36: 298-300 (2007)
  • Floating Thrombus in the Descending Aorta   K. Matsuki, et al.……301
    Floating Thrombus in the Descending Aorta

    (Department of Cardiovascular Surgery, Hachinohe City Hospital, Hachinohe, Japan and Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University*, Sendai, Japan)

    Katsuo Matsuki Hidenori Fujiwara Katsuhiko Oda*
    Floating masses in the descending aorta are an uncommon source of embolism. We report a 43-year-old woman, with no previous history of thrombotic events, who was admitted to our hospital for renal and splenic infarction. Transesophageal echocardiography and computed tomography showed a floating mass in the descending aorta. We started anticoagulant therapy immediately and performed surgical removal of the mass that had caused multiple embolic episodes. The postoperative course was uneventful. In cases of a free floating thrombus in the aorta, it is important to prevent catastrophic complications by removing it surgically after anticoagulant therapy.
     Jpn. J. Cardiovasc. Surg. 36: 301-304 (2007)
  • A Novel Approach to Surgical Treatment of Scimitar Syndrome: Relocation of the  Anomalous Pulmonary Vein and Intra-Atrial Baffle Rerouting   Y. Uno, et al.……305
    A Novel Approach to Surgical Treatment of Scimitar Syndrome: Relocation of the Anomalous Pulmonary Vein and Intra-Atrial Baffle Rerouting

    (Department of Cardiovascular Surgery, Tokyo Metropolitan Children’s Hospital, Kiyose, Japan)

    Yoshimasa Uno Takaaki Suzuki Kentaro Hotoda
    Osamu Ishida Toyoki Fukuda
    Scimitar syndrome is a rare congenital cardiac anomaly with anomalous right pulmonary veins draining to the inferior caval vein. Currently, it is widely accepted that there are 2 forms of presentation with either an infantile manifestation or an adult form. Patients in the latter category are usually less severely affected and frequently asymptomatic on diagnosis. A 16-year-old boy who had been given a diagnosis of scimitar syndrome was observed for years because of his unwillingness to undergo surgery. However, since the latest catheter examination demonstrated an elevated pulmonary-to-systemic flow ratio of 2.39, he consented to undergo surgical treatment. Preoperative studies demonstrated an intact atrial septum and abnormal bronchial arborization of the right lung. Pulmonary angiography demonstrated abnormal right pulmonary veins that converged to a single venous trunk, the so-called scimitar vein, and drained into the inferior caval vein at the level of diaphragma. Because of the morphological abnormalities including a wide distance between the pulmonary veno-caval junction and interatrial septum, counterclockwise rotation of the heart, and a small left atrium, surgical management was performed with a novel approach, consisting of relocation of the scimitar vein to the anterolateral wall of the right atrium, total excision of the oval fossa, and intra-atrial baffle rerouting with the pulmonary venous blood being conveyed to the left atrium through the atrial septal defect. During the cardiopulmonary bypass vacuum assisted venous drainage through a femoral venous cannula was highly effective to secure a clear operative field without occlusion of the inferior caval vein. Postoperative recovery was uneventful and the repeat Doppler echocardiography demonstrated an unobstructed flow through the baffle. This experience indicates that the above novel approach is a promising surgical option for the management of scimitar syndrome.
     Jpn. J. Cardiovasc. Surg. 36: 305-308 (2007)