Japanese Journal of Cardiovascular Surgery Vol.36, No.6

Review

• Mid-Term Clinical Results of Tissue-Engineered Vascular Autografts 　　G. Matsumura, et al.……309

  Mid-Term Clinical Results of Tissue-Engineered Vascular Autografts

  (Department of Cardiovascular Surgery* and International Research and Educational Institute for Integrated Medical Sciences**, Tokyo Women’s Medical University, Tokyo, Japan) Goki Matsumura*,** Toshiharu Shin’oka*,** Narutoshi Hibino* Satoshi Saito* Takahiko Sakamoto* Yuki Ichihara* Kyoko Hobo* Shin’ka Miyamoto*,** Hiromi Kurosawa*,**

  Prosthetic and bioprosthetic materials currently in use lack growth potential and therefore must be repeatedly replaced in pediatric patients as they grow. Tissue engineering is a new discipline that offers the potential for creating replacement structures from autologous cells and biodegradable polymer scaffolds. In May 2000, we initiated clinical application of tissue-engineered vascular grafts seeded with cultured cells. However, cell culturing is time-consuming, and xenoserum must be used. To overcome these disadvantages, we began to use bone marrow cells, readily available on the day of surgery, as a cell source. Since September 2001, tissue-engineered grafts seeded with autologous bone marrow cells have been implanted in 44 patients. The patients or their parents were fully informed and had given consent to the procedure. A3 to 10ml/kg specimen of bone marrow was aspirated with the patient under general anesthesia before the skin incision. The polymer tube serving as a scaffold for the cells was composed of a copolymer of lactide and ε-caprolactone (50：50) which degrades by hydrolysis. Polyglycolic or poly-l-lactic acid woven fabric was used for reinforcement. Twenty-six tissue-engineered conduits and 19 tissue-engineered patches were used for the repair of congenital heart defects. The patients’ ages ranged from 1 to 24 years (median 7.4 years). All patients underwent a catheterization study, CT scan, or both, for evaluation after the operation. There were 4 late deaths due to heart failure with or without multiple organ failure or brain bleeding in this series; these were unrelated to the tissue-engineered graft function. One patient required percutaneous balloon angioplasty for tubular graft-stenosis and 4 patients for the stenosis of the patch-shaped tissue engineered material. Two patients required re-do operation; one for recurrent pulmonary stenosis and another for a resulting R-L shunt after the lateral tunnel method. Kaplan-Meier analysis in relation to patients’ survival was 95% within 3 years. There was only 1 patient (who underwent a total cavo-pulmonary connection procedure) requiring re-intervention in the tubular graft group and the material-related event-free rate was 96% within 3 years. This tissue-engineering approach may provide an important alternative to the use of prosthetic materials in the field of pediatric cardiovascular surgery. As it is living tissue, these vascular structures may have the potential for growth, repair, and remodeling. However, this approach is still in its infancy, further studies to resolve the problems presented, and longer follow-up in patients are necessary to confirm the durability of this approach. 　Jpn. J. Cardiovasc. Surg. 36: 309-314 (2007)

Originals

• Aortic Root Replacement for Destructive Aortic Valve Endocarditis or Aortitis 　　K. Okada, et al.……315

  Aortic Root Replacement for Destructive Aortic Valve Endocarditis or Aortitis

  (Division of Cardiovascular, Thoracic and Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan) Kenji Okada Hiroshi Tanaka Naoto Morimoto Hiroshi Munakata Mitsuru Asano Masamichi Matsumori Atsushi Kitagawa Yujiro Kawanishi Keitaro Nakagiri Yutaka Okita

  Destructive aortic valve endocarditis or poor controlled aortitis cause the development of left ventricular-aortic discontinuity. We reported our experience with aortic root replacement for cases of severe aortic annular destruction. Between 1999 and 2006, 9 patients with severe aortic annular destruction underwent aortic root replacement at our institute. There were 8 men and one women with a mean age of 55 years. Seven patients were in New York Heart Association functional class III. Four of 9 patients had native valve endocarditis, 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2, aortic root replacements in 2) and one had active aortitis with a detached mechanical valve. Radical debridement of the infected cavity and necrotic tissue was performed in all cases, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 3 cases. Antibiotic-saturated fibrin glue was applied to the cavity. Aortic root replacement was achieved with a pulmonary autograft (Ross procedure) in 4 and stentless aortic root xenograft in 4. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary implantation method. No mortality was observed during hospitalization and follow-up. Reoperation within 5 years was not necessary in 66.7% of the patients. Excellent outcome can be achieved by radical exclusion of the abscess cavity and viable pulmonary autograft or stentless aortic root xenograft in patients with severe aortic annular destruction. 　Jpn. J. Cardiovasc. Surg. 36: 315-320 (2007)

• Serial Angiographic Evaluation Over 5 Years after Coronary Bypass Surgery 　　K. Onoguchi, et al.……321

  Serial Angiographic Evaluation Over 5 Years after Coronary Bypass Surgery

  (Division of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan, Department of Cardiovascular Surgery, Jikei University School of Medicine*, Tokyo, Japan and Department of Cardiovascular Surgery, Shizuoka Red Cross Hospital**, Shizuoka, Japan) Katsuhisa Onoguchi Kazuhiro Hashimoto* Shigeki Higashi** Hiromitsu Takakura Takashi Hachiya Noriyasu Kawada Takahiro Inoue Tatsuro Takahashi Tatsuumi Sasaki

  This study was designed to evaluate the late changes of coronary bypass grafts in 60 patients who had undergone coronary bypass surgery and postoperative angiography in the period from 1994 to 1999. Angiography was performed at mean intervals of 84 months and a total of 134 grafts and 162 anastomoses were visualized. The Left internal thoracic artery and saphenous vein had a patency of 85% and 82%, there was not statistically significant. In this series, late graft function did not relate to the site of implantation, that was mainly due to excellent results of saphenous vein grafts. With increasing proximal stenosis severity (under 75% versus over 90%), there was an increase in patency rates and this relationship was statistically significant (p＝0.0005). That was why about 20% of the grafts to moderately stenotic target vessels had occluded within 1 month after surgery. Ten patients among these 60 had cardiac symptoms, 6 were due to graft failure and the other 4 were due to new lesions in the right coronary artery. In the other 12 patients new coronary artery lesions without cardiac symptoms had been detected. Periodic coronary examinations should be recommended for the patients after surgery, regardless of the absence of symptoms. 　Jpn. J. Cardiovasc. Surg. 36:321-324 (2007)

Case Reports

• Surgical Repair of Giant Coronary Artery Aneurysm Associated with Coronary-Pulmonary Artery Fistulae in a 73-Year-Old Woman 　　K. Nakamura, et al.……325

  Surgical Repair of Giant Coronary Artery Aneurysm Associated with Coronary-Pulmonary Artery Fistulae in a 73-Year-Old Woman

  (Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Matsudo, Japan) Koki Nakamura Yosuke Saito Tomohiro Asai Mikiko Murakami Yuji Suda Hiroki Yamaguchi

  A 73-year-old woman was referred to our hospital with a feeling of chest compression. Coronary angiography revealed a giant coronary artery aneurysm, located in the middle of a coronary-pulmonary artery fistula originating at the left anterior descending artery. Also another fistula was shown between the right coronary artery and the pulmonary artery. Surgical correction was indicated due to the risks of the aneurysm rupture and coronary events. Under cardiopulmonary bypass, suture-closure of the coronary artery aneurysm and ligation of the fistulae were carried out with success. Transesophageal echocardiography was useful to confirm disappearance of the abnormal shunts after the operative procedures. The postoperative course was uneventful. Postoperative coronary angiography showed no aneurysm or fistula. She was discharged on the 11th postoperative day on foot. 　Jpn. J. Cardiovasc. Surg. 36: 325-328 (2007)

• A Case of Double Valve Replacement with Antiphospholipid Syndrome 　　H. Yusa, et al.……329

  A Case of Double Valve Replacement with Antiphospholipid Syndrome

  (Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan) Hiroaki Yusa Yasushi Nishiya Akira Murata Norihiko Saitoh Shuichi Hoshino

  A 39-year-old woman was found to have a heart murmur by a medical examination at age 37. During a checkup at our hospital, echocardiography revealed mild aortic valve regurgitation (AR) and mild mitral valve regurgitation (MR). When she was 39 years old, echocardiography revealed severe MR and moderate AR. Based on preoperative examinations, antiphospholipid syndrome (APS) was diagnosed. Therefore, she received high-dose prednisolone therapy and underwent plasma exchange before the surgery. We performed double valve replacement using a bioprosthetic valve. On the first postoperative day (POD1), the number of platelets suddenly decreased. We diagnosed catastrophic APS, and treated her with high-dose prednisolone, high-dose immunoglobulin and plasma exchange. Her blood platelet gradually increased on POD3. Although she needed time for rehabilitation, she was discharged from our hospital on POD88. APS can cause a catastrophic event triggered by an operation. Therefore, stringent pre- and postoperative management is necessary in patients with APS. 　Jpn. J. Cardiovasc. Surg. 36: 329-332 (2007)

• A Patient Who Underwent Mitral Annuloplasty for Mitral-Valve Insufficiency due to Calcification of the Mitral-Valve Annulus 　　T. Minami, et al.……333

  A Patient Who Underwent Mitral Annuloplasty for Mitral-Valve Insufficiency due to Calcification of the Mitral-Valve Annulus

  (Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan and First Department of Surgery, Yokohama City University*, Yokohama, Japan) Tomoyuki Minami Kiyotaka Imoto Shin-ichi Suzuki Keiji Uchida Norihisa Karube Koichiro Date Motohiko Goda Toshiki Hatsune Munetaka Masuda*

  A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular end-diastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy. 　Jpn. J. Cardiovasc. Surg.36: 333-336 (2007)

• Oldest Reported Surviving Patient with a Ruptured Abdominal Aortic Aneurysm with Shock: Expertly Coordinated and Trained Medical Teams Save a 　96-Year-Old Patient 　　T. Matsumoto, et al.……337

  Oldest Reported Surviving Patient with a Ruptured Abdominal Aortic Aneurysm with Shock: Expertly Coordinated and Trained Medical Teams Save a 96-Year-Old Patient

  (Department of Surgery, Fukuoka Saiseikai Hospital, Fukuoka, Japan, Department of Surgery, Karatsu Saiseikai Hospital*, Saga, Japan and Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University**, Fukuoka, Japan) Takuya Matsumoto* Atsushi Fukuda Yoshihiko Maehara** Kenichiro Okadome

  We report possibly the oldest patient in the world with both a ruptured abdominal aortic aneurysm and shock who was saved by accurate diagnosis and immediate treatment by trained medical teams specializing in emergency medicine, radiology, vascular surgery, anesthesiology, and internal medicine. The 96-year-old patient was transferred to our hospital because of sudden left lateral abdominal pain and hypotension that resulted in periods of unconsciousness and shock. An enhanced CT scan showed that the ruptured infrarenal abdominal aortic aneurysm was surrounded by hematoma that was located mainly in the left lateral abdomen, extended above the renal arteries (Fitzgerald type III), and was 7cm at its maximum diameter. Y-graft replacement was successfully performed after a rapid decrease in the patient’s blood pressure was quickly restored by clamping the aortic neck by hand. Following the operation the patient developed ischemic colitis and cholecystitis, which were cured by conservative treatment. The patient was discharged 20 days after the operation. We were able to save this nonagenarian patient with both a ruptured abdominal aortic aneurysm and shock by immediate treatment provided by medical teams that are trained and coordinated. 　Jpn. J. Cardiovasc. Surg. 36: 337-341 (2007)

• A Case of Coronary Artery Bypass Grafting with Essential Thrombocythemia 　　S. Hamada, et al.……342

  A Case of Coronary Artery Bypass Grafting with Essential Thrombocythemia

  (Division of Cardiovascular Surgery, Department of Surgery (Omori), School of Medicine, Toho University, Tokyo, Japan) Satoshi Hamada Yoshinori Watanabe Noritsugu Shiono Muneyasu Kawasaki Takeshirou Fujii Tsukasa Ozawa Hiroshi Masuhara Nobuya Koyama

  We experienced the coronary artery bypass grafting (CABG) with essential thrombocythemia (ET). A case is a man of 73 years old. As for him, 3 vessel disease including left main trunk was recognized on coronary angiography, and it was planned CABG. However, we recognized blood cell aberration in blood examination, and it was diagnosed as ET. ET is classed as a chronic myeloproliferative disorder. It has two opposite tendencies, a bleeding tendency and thrombus tendency. Ischemic heart disease to merge ET is acute myocardial infarction by thrombus in case of most, and there are a few cases to need blood circulation reconstruction of coronary artery for angina pectoris. Perioperative hemorrhage and postoperative graft closure become a problem in CABG with ET. With the hydroxycarbamide which is DNA synthesis inhibitor of a platelet count, a function controlled it, and enforced CABG. He doesn’t have any cardiac events and complications due to ET for 7 years post CABG. We report this case with a review of the literature. 　Jpn. J. Cardiovasc. Surg. 36: 342-344 (2007)

• Surgical Treatment of Pulmonary Artery Aneurysm Thirty-Eight Years after an Operation for Atrial Septal Defect 　　K. Ono, et al.……345

  Surgical Treatment of Pulmonary Artery Aneurysm Thirty-Eight Years after an Operation for Atrial Septal Defect

  (Department of Cardiovascular Surgery, San-in Rousai Hospital, Yonago, Japan) Kimiyo Ono Naoaki Takemoto Hiroaki Kuroda

  Pulmonary artery aneurysm (PAA) may be associated with congenital shunt disease such as patent ductus arteriosus, and its frequency and management are often controversial. We report successful surgical treatment of PAA following an operation for atrial septal defect (ASD). The patient was a 47-year-old woman who underwent closure of ASD at the age of 9. When she was investigated because of thyroid tumor, enlargement of her main pulmonary artery was pointed out and she was admitted to our hospital. Several examinations revealed a diagnosis of pulmonary valve insufficiency and 70mm PAA with dilatation extending to both proximal arteries. We performed replacements of pulmonary valve and pulmonary artery with a bioprosthetic valve and T-shaped graft. The patient is doing well 2 years after operation. 　Jpn. J. Cardiovasc. Surg. 36: 345-347 (2007)

• A Case of Infective Endocarditis in Which Surgical Removal of Both Eyes Was 　Inevitable because of Bacterial Endopthalmitis 　　Y. Takamoto, et al.……348

  A Case of Infective Endocarditis in Which Surgical Removal of Both Eyes Was Inevitable because of Bacterial Endopthalmitis

  (Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan) Yayoi Takamoto Ryuji Kunitomo Toshiharu Sassa Hisashi Sakaguchi Syoichiro Hagiwara Shuji Moriyama Kentaro Takaji Michio Kawasuji

  Bacterial endopthalmitis is associated with risk for poor visual prognosis, however, it is rarely combined with infective endocarditis. A 66-year-old man underwent pacemaker implantation and received antibiotic therapy due to persistent fever. A month after the pacemaker implantation, he was admitted to our hospital because of disturbance of vision and consciousness. Disseminated intravascular coagulation (DIC) with decrease of platelet count was also present. His eyes were reddish and swelled, and the conjunctiva were turbid and edematous in both sides. Transesophageal echocardiography demonstrated 18×13mm pendulous verruca originating from the tricuspid annulus. The patient underwent concomitant resection and repair of the tricuspid valve and removal of both infected eyes after DIC treatment. The postoperative course was uneventful and he was discharged from the hospital 43 days after the operation. We conclude that careful observation of the eyes may be needed for patients with infective endocarditis when they have some visual symptoms. 　Jpn. J. Cardiovasc. Surg. 36: 348-351 (2007)

• Redo Total Arch Replacement in Two Cases 　　K. Ohkura, et al.……352

  Redo Total Arch Replacement in Two Cases

  (Department of Cardiovascular Surgery, National Obihiro Hospital, Obihiro, Japan) Kazuhiro Ohkura Yoichi Kikuchi Chikara Shiiku Keijirou Mitsube

  We performed redo total arch replacement for recurring aortic arch diseases in 2 patients. Case1: A 76-year-old man with 3 prior surgical interventions for aortic arch diseases was referred to our hospital for the treatment of a ruptured aortic arch pseudoaneurysm. On admission, he frequently coughed up bloody sputum. Emergency total arch replacement was performed in this patient. Case2: A 77-year-old man who had undergone total arch replacement 9 years previously recently experienced hoarseness. A CT-scan revealed distal aortic arch aneurysm, for which we decided to perform a redo total arch replacement. Surgical strategy was similar for both patients. Cardiopulmonary bypass was established and cooling was started before resternotomy. Redo total arch replacement assisted by antegrade selective cerebral perfusion was performed using 4-branched arch grafts. Although both patients were weaned from mechanical ventilator support, the first patient died of aspiration pneumonia on the 150th postoperative day, while the second one is currently undergoing rehabilitation at our hospital. Hospital mortality is high among patients undergoing redo thoracic aortic replacement requiring resternotomy. In these patients, it is important to pursue an appropriate operative procedure and to minimize pulmonary complications. 　Jpn. J. Cardiovasc. Surg. 36: 352-355 (2007)

• Ultrasound-Guided Thrombin Injection Therapy for the Treatment of Iatrogenic 　Femoral Pseudoaneurysms 　　M. Yokokawa……356

  Ultrasound-Guided Thrombin Injection Therapy for the Treatment of Iatrogenic Femoral Pseudoaneurysms

  (Department of Thoracic and Vascular Surgery, Takaoka City Hospital, Takaoka, Japan) Masayasu Yokokawa

  Femoral pseudoaneurysm is a common complication in percutaneous catheterization. Ultrasound-guided thrombin injection (UGTI) therapy has been developed as a less invasive and highly successful treatment of a femoral pseudoaneurysm. We performed UGTI therapy for 3 patients with iatrogenic femoral pseudoaneurysms that formed after femoral artery catheterization. Case1 was a 76-year-old woman. Following the catheterization procedure, she developed a right femoral pseudoaneurysm and refused operative repair. After obtaining informed consent, we performed UGTI therapy for the pseudoaneurysm. Immediately after the treatment, the pain caused by the pseudoaneurysm disappeared and no recurrence has been seen. Case2 was a 72-year-old woman. Following withdrawal of the transfemoral catheter, a right femoral pseudoaneurysm appeared. We performed UGTI therapy for the pseudoaneurysm, which became thrombotic after treatment. Case3 was an 87-year-old man with a right femoral pseudoaneurysm after the catheterization procedure. We performed UGTI therapy for the pseudoaneurysm on 2 separate occasions, however, recurrence occurred following both and he finally underwent open surgical repair. In the present Cases1, 2, and 3, the sizes of the catheters used were 6, 8, and 11.5 Fr, respectively. Two of the patients were receiving percutaneous coronary artery intervention and continued undergoing anticoagulant therapy at the time of the injection. For all 3 patients, we injected human thrombin into the pseudoaneurysm percutaneously under ultrasound guide. Cases1 and 2 had no recurrence after the first treatment, whereas Case3 had 2 instances of pseudoaneurysm recurrence after treatment and finally received surgical repair. There were no complications derived from the treatment in any of the cases, nor was there evidence of embolism or allergic reaction originating from the thrombin. We concluded that UGTI therapy should be considered as an alternative treatment for a femoral pseudoaneurysm that occurs after catheterization. 　Jpn. J. Cardiovasc. Surg. 36: 356-360 (2007)

• Transfusion-Free Surgery for a Jehovah’s Witness Patient with Dilated Cardiomyopathy Treated with Mitral Complex Reconstruction 　　M. Motohashi, et al.……361

  Transfusion-Free Surgery for a Jehovah’s Witness Patient with Dilated Cardiomyopathy Treated with Mitral Complex Reconstruction

  (Department of Cardiovascular Surgery, NTT East Sapporo Hospital, Sapporo, Japan, Division of Medical Sciences, Health Sciences University of Hokkaido*, Hokkaido, Japan and Department of Cardiovascular Surgery, Hokkaido University Hospital**, Sapporo, Japan) Masatoshi Motohashi Akira Adachi Ko Takigami Keishu Yasuda Shigeyuki Sasaki* Yoshiro Matsui**

  A 22-year-old man with dilated cardiomyopathy (DCM), who was a practicing Jehovah’s Witness, was transferred to our hospital for surgical treatment of medically uncontrollable mitral regurgitation (MR). Our original mitral complex reconstruction procedure and permanent pacemaker implantation for biventricular pacing were successfully performed without transfusion of blood products. Blood conservation strategy included: 1) preoperative treatment with erythropoietin, 2) utilization of a shortened extracorporeal circuit and assisted venous drainage system, 3) the use of ultrafiltration to save the residual autoblood in the extracorporeal circuit. The preoperative hemoglobin level was 17.1g/dl and the postoperative lowest level was 9.5g/dl. MR decreased from grade III to none, and NYHA functional class improved from class II to class I postoperatively. He was moved to a cardiology ward on the 13th postoperative day without complications. Transfusion-free surgery for DCM should be performed before DCM advances and requires left ventriculoplasty at risk for major blood loss. A careful follow-up is needed to examine the long-term results of the operative procedure during his expected long survival. 　Jpn. J. Cardiovasc. Surg. 36: 361-365 (2007)