|Early Diagnosis and Therapy of Non-occlusive Mesenteric Ischemia after Open Heart Surgery
|Non-occlusive mesenteric ischemia (NOMI) is a rare but often fatal event following cardiac surgery. Early diagnosis of NOMI is difficult because the related abdominal symptoms are not very specific. From April 1999 to September 2003, 1,040 patients underwent cardiac surgery, among whom 5 patients who underwent angiography were given a diagnosis of NOMI. A catheter was used for immediate intra-arterial infusion of 500μg prostaglandin E1 into the superior mesenteric artery over a period of 30min, Prior to angiography, all patients had cutis marmorata and elevated serum lactate levels. Three patients showed peritoneal signs and therefore underwent laparotomy. Of the 5 patients, 4 survived. In conclusion, if mesenteric ischemia is suspected, selective angiography must be performed as soon as possible for diagnosis and treatment. Additionally, the presence of other findings such as cutis marmorata and elevated serum lactate levels proved to be useful in the early diagnosis of NOMI.
Jpn. J. Cardiovasc. Surg. 37: 69-73 (2008)
|Evaluation of the Enclose® II Anastomosis Device during Off-Pump Coronary Artery Surgery
|The aim of this study was to
evaluate the Enclose II anastomosis device (Novare Surgical
System, Inc., Cupertino, CA). A retrospective record review
was conducted of all cases which underwent off-pump coronary
artery bypass surgery (OPCAB) at our general hospital
between January 2002 and December 2006. We identified
91 patients (a mean age of 71.0 years, the average number
of distal anastomoses 2.5/patient) underwent OPCAB. The
proximal anastomoses were constructed with the Enclose
II (group E, 40 patients), aorta side-clamp technique
(group S, 17 patients), and aorta no touch (group N, 34
patients). Group E had more grafts than group N (E:N＝2.7:1.7/patient,
p＜0.0001), while Group E (3.1/patient) had more distal
anastomoses than group S (2.6/patient, p＝0.0486) and N
(1.8/patient, p＜0.0001). There was no difference of graft
patency in each group (early; E:S:N＝99.1%:97.8%:98.0%,
1-year; E:S:N＝95.8%:91.3%:95.2%). There was no patient
with sustained permanent neurologic deficits after OPCAB.
The Novare Enclose Ⅱ proximal anastomotic device appears
to be a safe and effective tool during OPCAB.
Jpn. J. Cardiovasc. Surg. 37: 74-77 (2008)
|Mid-Term Outcome after Repair of Tetralogy of Fallot with Absent Pulmonary Valve
|Absent pulmonary valve (APV) syndrome is a rare anomaly that is usually associated with tetralogy of Fallot (TOF) and causes severe respiratory distress by compression of the trachea. Mortality following surgical repair in these patients is increased, especially in infants presenting with severe respiratory compromise. Preoperative ventilator dependency and age at operation are risk factors for mortality after surgical repair. Between 1995 and 1999, 5 patients underwent surgical treatment for TOF with APV. The mean age at operation was 9 months (range: 1 to 29 months), and the mean weight at operation was 5.2kg (3.6-9.1kg). Among these patients, 3 patients presented with severe respiratory distress caused by dilatation of aneurysmal pulmonary artery (pulmonary artery index＞2,000) and 2 of these patients were dependent on a respirator prior to surgical treatment. Reduction of dilated pulmonary artery, including anterior wall resection and posterior placation, was performed in all patients. In the patients with severe preoperative respiratory compromise, the right ventricular outflow tract was reconstructed with an extracardiac conduit with autologous pericardial valve leaflets to avoid pulmonary valve regurgitation after the operation and a transannular patch with a PTFE valve was used in 2 patients without respiratory compromise. One patient died suddenly 7 months after surgical intervention. Three of the surviving patients underwent a second right ventricular outflow tract reconstruction because of progressive right ventricular outflow tract stenosis. In two of these patients the right ventricular outflow tract was reconstructed with an extracardiac conduit with autologous pericardial valve leaflets at first operation. All surviving patients are well without any physical limitations and have been placed in NYHA classⅠ. Despite the need for reoperation for right ventricular outflow tract stenosis, aggressive surgical treatment for TOF with APV has produced a satisfactory mid-term outcome.
Jpn. J. Cardiovasc. Surg. 37: 78-81 (2008)
|Effects of Edaravone on Prevention of Paraplegia Caused by Ischemic Spinal Cord
|Spinal cord injury after successful operation of the thoraco-abdominal aorta is an unpredictable complication which negatively affects the patient’s quality of life. The main cause of spinal cord injury has been reported to be peroxidation of lipids. Edaravone, a free radical scavenger, has been used in the acute phase of cerebral infarction to ameliorate the brain damage. The aim of the present study was to evaluate the protective effect of edaravone on the neurological and histological outcome, and to examine the method of its administration so as to obtain the better effect, using animal models with ischemic spinal cord. Three groups of rabbits underwent surgical exposure of the abdominal aorta that was clamped for 20min to achieve spinal cord ischemia. Group A (n＝6, control group) was given no medication. In group B (n＝6), edaravone (3mg/ml saline/kg body weight) was administered intravenously 30min after reperfusion. In group C (n＝6), the same dose of edaravone was administered at 30min, 24h and 48h after reperfusion. Neurological status was clinically assessed, using Tarlov’s score, at 24h, 48h and 1week after reperfusion. Somatosensory evoked potential was measured preoperatively, at 20min after ischemia, at 30min after reperfusion, and at 24h, 48h and 1week after operation. Spinal cord sections were examined histologically to determine the degree of neuronal damage given by ischemic-reperfusion. Group A presented paraplegia with marked neuronal necrosis. Groups B and C maintained better neurogical function than Group A (p＜0.001), and Group C was much better than Group B (p＜0.05). In the model rabbits with 20min of ischemia-reperfusion, systemic repetitious administration of edaravone was found to have a more protective effect than a single administration on the spinal cord neurons and glia cells both neurologically and histologically.
Jpn. J. Cardiovasc. Surg. 37: 82-90 (2008)
|Effect of Sivelestat Sodium Hydrate on Postoperative Respiratory Failure due to Acute Aortic Dissection
|Acute respiratory failure after cardiopulmonary bypass is a severe postoperative complication. We evaluated the effects of a specific neutrophil elastase inhibitor, sivelestat sodium hydrate (Ono Pharma Co. Ltd., Osaka, Japan), on postoperative respiratory failure due to acute aortic dissection (type A, AAD). A retrospective review of clinical records was conducted for all cases of emergency surgery for AAD at Ome Municipal General Hospital between June 2001 and August 2006. We identified 16 patients (median age, 64.9 years old; male: female ratio, 4:12) who had an initial postoperative PaO2/FIO2 of less than 300mmHg. Among these patients, 11 treated with sivelestat were compared with 5 (the control group) who did not receive sivelestat. There were no significant differences in age, body weight, sex, operating time, cardiopulmonary time, blood transfusion, initial WBC and CRP between the two groups. At arrival in the ICU, the patients in the sivelestat group had a worse respiratory condition based on parameters such as PaO2/FiO2 (sivelestat vs. control, 74.1 vs. 181.1mmHg, p＝0.0007), A-aDO2 (sivelestat vs. control, 620.3 vs. 556.7mmHg, p＝0.0003), and respiratory index (sivelestat vs. control, 9.29 vs. 4.92, p＝0.0002). However, the patients in the sivelestat group showed a greater improvement in these parameters and CRP over a 3-day observation period, compared to those in the control group. We conclude that sivelestat may attenuate postoperative respiratory complications in patients with AAD.
Jpn. J. Cardiovasc. Surg. 37: 91-95 (2008)
|Detection of Late Presentation of Poststernotomy Mediastinitis in an Infant by Positron Emission Tomography
|Positron emission tomography
(PET) is an established imaging tool in oncology that
has also been used in infectious and inflammatory diseases.
PET combined with computed tomography (PET/CT) can be
used to visualize metabolic activity with precise localization.
We report an infant with late presentation of poststernotomy
mediastinitis, the diagnosis and localization of which
was confirmed by PET/CT. An 8-month old infant, who had
undergone the Jatene procedure and right ventricle outflow
reconstruction 6 months prior, was admitted for inflammation
surrounding the superior aspect of the healed scar. Cultures
from the wound grew methicillin-resistant Staphylococcus
aureus (MRSA). Although the only symptom was discharge
from the wound, and there were no other signs or symptoms
suggestive of severe general infection, substernal abscess
was suspected by magnetic resonance imaging. Since PET/CT
revealed high accumulation of 18-fluorodeoxyglucose at
the substernal region, the diagnosis of MRSA mediastinitis
was made, which was confirmed by subsequent surgical treatment.
Jpn. J. Cardiovasc. Surg. 37: 96-99 (2008)
|Surgical Treatment of Pulmonary Valve Disease Associated with Pulmonary Arterial Dilatation in the Adult: Reports of Two Cases
|Pulmonary artery (PA) aneurysm
is rare, but its true incidence is unclear, because most
cases remain asymptomatic. The need for surgical treatment
is controversial. We report two cases of surgical treatment
of PA aneurysm associated with pulmonary valve (PV) disease
in adults. Case1: A 54-year-old woman. She underwent pulmonary
valvotomy for pulmonary stenosis (PS) at age 22. She had
suffered from palpitations and dyspnea on effort recently.
Then progressive changes of pulmonary stenosis-regurgitation
(PSR) occurred. After further examinations, she was diagnosed
as having PA aneurysm and right ventricular dysfunction
with PSR, tricuspid regurgitation and paroxysmal atrial
fibrillation. We performed PV replacement, PA aneurysmo-plasty,
tricuspid annuloplasty, cryo-MAZE procedure. Case2: A
70-year-old man sufferd recently from dyspnea on effort.
The dilatation of the pulmonary artery was pointed out
on chest X-ray. PA aneurysm and PS with ventricular arrhythmia
were diagnosed. We performed PV commissurotomy and PA
aneurysmo-plasty. There were no significant findings of
high PA pressure in either case. PA with pulmonary valve
disease in the presence of low pulmonary pressure have
low risk of rupture and dissection. Surgical treatments
are recommended when right ventricular dysfunction or
ventricular arrhythmia secondary to pulmonary valve disease
Jpn. J. Cardiovasc. Surg. 37: 100-103 (2008)
|Mitral and Tricuspid Valve Repair in a Patient with an Absent Right and Persistent Left Superior Vena Cava
|Absence of the right superior vena cava with persistent left superior vena cava without any other cardiac anomalies in visceroatrial situs solitus is rare. A 41-year-old man presented with a feeling of anterior chest pressure on effort. Severe mitral regurgitation due to anterior prolapse of the A2-A3 segments and moderate tricuspid regurgitation were diagnosed. Three-dimensional CT scan revealed an absent right and persistent left superior vena cava. Electrocardiographic findings showed a typical coronary sinus rhythm. At operation, a pulmonary artery catheter was placed via the right femoral vein under fluoroscopy. After starting cardiopulmonary bypass with a single venous cannula in the inferior vena cava, an L-shaped venous cannula was directly placed into the left superior vena cava. Mitral valve repair was performed, with 4 pairs of Gore-Tex CV-5 artificial chordae and mitral ring annuloplasty through a standard transverse left atriotomy. Tricuspid ring annuloplasty was also performed. His postoperative course was uneventful. Postoperative echocardiography showed only trivial mitral and tricuspid regurgitation. In patients with such venous anomalies, the area around the coronary sinus should be protected during intracardiac procedures to preserve the coronary sinus rhythm. We therefore recommend direct venous cannulation of the left superior vena cava instead of retrograde cannulation via the coronary sinus, and standard transverse left atriotomy for mitral exposure.
Jpn. J. Cardiovasc. Surg. 37: 104-107 (2008)
|Cardiac Surgery in a Patient with Idiopathic Thrombocytopenic Purpura: Preoperative High-Dose Immunoglobulin Therapy
|A 62-year-old woman with idiopathic thrombocytopenic purpura (ITP) was admitted to undergo cardiac surgery for aortic stenosis, angina pectoris, and paroxysmal atrial fibrillation. A bleeding tendency was expected due to the dramatic decrease in platelets during cardiopulmonary bypass. We performed high-dose transvenous gammaglobulin infusion (400mg/kg/day) for 5 consecutive days immediately before surgery. The gammaglobulin therapy caused steady increase of thrombocytes from 4 days after surgery, even though the platelet count showed no significant change preoperatively. The postoperative course was satisfactory with neither a bleeding tendency nor wound infection. High-dose transvenous gammaglobulin therapy is thus useful for perioperative patients with accompanying ITP, who are often under medication with steroids. This therapy is also effective for prevention of infection.
Jpn. J. Cardiovasc. Surg. 37: 108-111 (2008)
|Effectiveness of Assisted Ventilation Supplemented by RTX and NPPV for the Prevention of Postoperative Respiratory Failure in a Patient with Severe COPD Undergoing Total Arch Replacement
|A 74-year-old man with very severe chronic obstructive pulmonary disease (COPD) was scheduled for elective total arch replacement for a distal arch saccular aneurysm. Postoperative respiratory failure was anticipated because of a marked reduction in forced expiratory volume in one second (FEV1.0- less than 0.5l ). Through median sternotomy, total arch replacement using selective cerebral perfusion was completed uneventfully. Postoperative respiratory condition was stable. Therefore, the patient was extubated on postoperative day 2 (POD2). However, as the respiratory condition started getting worse, respiratory therapy external (RTX) was introduced to assist ventilation. Additionally, non-invasive positive pressure ventilation (NPPV) with BiPAP was used on POD3 and management with both RTX and NPPV was continued during the remainder of the intensive care unit stay. As a result, we were able to avoid re-intubation. In conclusion, assisted ventilation supplemented by RTX and NPPV was useful for the prevention of postoperative respiratory failure in a patient with very severe COPD undergoing total arch replacement.
Jpn. J. Cardiovasc. Surg. 37: 112-115 (2008)
|A Case of Left Ventricular Reconstruction in a Patient with Systemic Lupus Erythematosus and Antiphospholipid Syndrome
|A 65-year-old man was referred to our hospital for surgical treatment of left ventricular aneurysm (LVA) with mural thrombus. Systemic lupus erythematosus had been diagnosed when he was 57 and antiphospholipid syndrome (APS) had been diagnosed at age 61. Steroid and anticoagulant therapy with warfarin has been continuously performed. He suffered acute myocardial infarction at the age of 64, and percutaneous coronary intervention was performed to the diagonal branch. Seven months later, coronary angiography showed occlusion of the diagonal branch and left ventriculography showed a large LVA. Left ventricular reconstruction was performed and his postoperative course was uneventful. Cardiac surgery for the patients with APS was reported to have high morbidity and mortality. Perioperative anticoagulant management was very important for such patients.
Jpn. J. Cardiovasc. Surg. 37: 116-119 (2008)
|Surgical Treatment for Thoracoabdominal Aneurysm with Severely Calcified Aorta
|We report a 59-year-old chronic hemodialysis patient with a thoracoabdominal aortic aneurysm, in whom the entire aortic wall and visceral branches were severely calcified. Using a staged operation approach, the celiac trunk and superior mesenteric artery were first bypassed with a composite graft made from a saphenous vein Y-graft and ePTFE. Next, we inserted a custom-made stent-graft, however, there was poor attachment at both the proximal and distal ends due to the severely calcified aortic wall. As a result, we used additional two stent-grafts. His postoperative course was good, and the CT scan performed one year after operation showed no endoleak.
Jpn. J. Cardiovasc. Surg. 37: 120-123 (2008)
|Repair of Mitral Valve Perforation Secondary Involved with Primary Aortic Valve Endocarditis
|A 23-year-old man had had a fever of unknown origin for a month. Aggravation of shortness of breath brought him to our hospital. After a close inspection, transthoracic and esophageal echocardiography (TEE) showed severe aortic valve regurgitation (AR) with vegetation extending for 25mm. The valve was bicuspid and the vegetation was on the left side valve. TEE also revealed a streak of mitral valve regurgitation (MR). In spite of continuous antibiotic therapy, congestive heart failure developed with progressive MR, so we performed an emergency operation. The aortic valve was bicuspid composed of an agglutinated left and non-coronary cusp, and 15×30mm vegetation was attached on the left. Checking the mitral valve after resection of aortic valve, we found a perforation 3mm in size at the center of the anterior mitral leaflet. After resection of the infected area, we repaired it with a Xenomedica patch 10mm in size through the aortic orifice. Two abscesses located beneath both leaflets were eradicated and finally aortic valve replacement was done with an SJM 23.
Jpn. J. Cardiovasc. Surg. 37: 124-127 (2008)
|A Surgical Case of CABG with Subclavian Steal Syndrome and Bilateral Iliac Type ASO
|Ischemic heart disease (IHD) may coexist with aorto-iliac occlusive disease, and concomitant revascularization procedures may be required. This study reports our experience with ascending aorta to left femoral bypass grafting (Ao-ltFG) to prepare for intra-aortic balloon pumping (IABP). A 73-year-old man with chest pain was admitted to our hospital. Coronary angiography revealed coronary aneurysm and IHD. Enhanced computed tomography showed coronary aneurysm, complete left subclavian artery occlusion and bilateral external iliac artery occlusion. We planned a two-stage operation. In the first operation, we chose coronary artery bypass grafting, excision of the coronary aneurysm and simultaneously Ao-ltFG to prepare for IABP. In the second operation, we chose axillo-axillo bypass grafting and Ao-ltFG to right femoral artery bypass grafting. Although in the operative findings no coronary aneurysm was recognized, we performed the other operations and the postoperative course was uneventful without IABP.
Jpn. J. Cardiovasc. Surg. 37: 128-131 (2008)
|Marfan’s Syndrome with Acute Aortic Dissection during Pregnancy
|A 26-year-old woman at 40 weeks of gestation attended our emergency department due to sudden onset of chest and back pain, although she had experienced no previous abnormalities. The patient was very tall, had spider fingers and scoliosis, all of which indicated Marfan’s syndrome. Enhanced computed tomography and cardiac ultrasonography revealed acute aortic dissection and annulo-aortic ectasia with aortic regurgitation. Thereafter, a baby weighing 3,070g was delivered by emergency Caesarean section and then a Bentall-type operation was performed consecutively. An intraoperative injection of heparin resulted in minimal uterine bleeding. Surgery at the 40th week of gestation was successful for both the mother and the neonate.
Jpn. J. Cardiovasc. Surg. 37: 132-135 (2008)
|A Case of Infective Endocarditis on an Annuloplasty Ring following Mitral Valve Repair
|Infective endocarditis on an annuloplasty ring following mitral valve repair is rare. A 59-year-old man underwent emergency sextuple coronary artery bypass grafting and mitral annuloplasty with a 26mm ring for acute myocardial infarction and mitral regurgitation. Seven weeks later, he was readmitted complaining of abdominal pain and diarrhea. He experienced high-grade fever with chills associated with leukocytosis and elevation of C reactive protein after gastroduodenal endoscopy. Although antibiotics were administered intravenously for several weeks, the fever persisted. Transesophageal echocardiography revealed vegetations on the mitral annuloplasty ring. Infective endocarditis was diagnosed as the culprit of the unknown fever and urgent surgery was indicated. Following redo median sternotomy, the heart was meticulously dissected out. On cardiopulmonary bypass with the heart arrested, left atriotomy was carried on the interatrial groove. Because of the small left atrium, Dubost incision was added for better mitral valve exposure. The infected annuloplasty ring was excised with the vegetations. The mitral valve was easily repaired because the valve leaflets had minimal changes except a small perforation at the base of the posterior middle scallop. After thorough debridement of the mitral valve, a glutaraldehyde-treated autologous pericardial strip was sutured along the annulus as a posterior pericardial band. Culture of the vegetation proved negative. His postoperative course was uneventful. He has been doing well for more than two and a half years with trivial mitral regurgitation and no recurrence of infection. According to the American Heart Association guidelines, endocarditis prophylaxis is not usually needed for gastrointestinal endoscopy, but is optional for high risk patients including those with prosthetic cardiac valves. Such a diagnostic procedure should be avoided soon after the application of an annuloplasty ring and if necessary, antiinfective prophylaxis may be indicated.
Jpn. J. Cardiovasc. Surg. 37: 136-139 (2008)
|Surgical Treatment for Papillary Muscle Rupture after Myocardial Infarction with Sustained Ventricular Tachycardia
|We report an operative case of papillary muscle rupture after myocardial infarction with sustained ventricular tachycardia. A 56-year-old man referred to our emergency room in shock. Emergency CAG showed total occlusion of the left circumflex artery, in which we placed a metallic stent. Even after re-canalization of the coronary artery was achieved, circulation was unstable. IABP and PCPS were used to maintain the systemic circulation. Trans-esophageal echocardiography showed papillary muscle rupture and massive mitral regurgitation. Under total cardiopulmonary bypass and cardiac arrest, we performed mitral valve replacement with a 27mm SJM mechanical valve. PCPS was continued after surgical treatment because of pulmonary congestion. Since the patient’s circulation and respiratory function improved, PCPS and IABP were removed on postoperative days 3 and 5. However, after removal of IABP, ventricular tachycardia appeared and IABP, PCPS were re-inserted. After adequate medication with Amiodarone and Carbedirol, ventricular tachycardia was controlled. PCPS and IABP were then removed uneventfully on postoperative days 14 and 19.
Jpn. J. Cardiovasc. Surg. 37: 140-143 (2008)
|A Successfully Treated Case of Primary Aortoenteric Fistula
|A 79-year-old man was transferred to our hospital because of massive hematemesis. Contrast-enhanced CT scan demonstrated extravasation of contrast medium into the jejunum. Therefore, we diagnosed primary aortoenteric fistula and performed an emergency operation. At surgical exploration, the jejunum was closely adherent to the normal-sized aorta. The fistula was present between the anterior wall of the aorta and the jejunum. Operative reconstruction was performed with in-situ grafting and a pedicled omentum flap was placed around the graft. The postoperative course was uneventful, and there has been no evidence of infection during the follow-up period of 1 year.
Jpn. J. Cardiovasc. Surg. 37: 144-146 (2008)
|Thoracoabdominal Aortic Dissection in a Patient with SLE
|Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease associated with the production of various autoantibodies and involvement of multiple organs. We report that steroid therapy for the SLE might play a major role in accelerating atherosclerosis and the patient suffered an aortic dissection. A 53-year-old woman had been receiving steroid therapy for 10 years due to SLE. The patient had thoracoabdominal aortic dissection. Conservative therapy was commenced, but the diameter of the dissecting aneurysm was enlarged. Therefore, grafting for the thoracic descending aorta and the abdominal aorta was performed. The patient experienced no significant postoperative complications.
Jpn. J. Cardiovasc. Surg. 37: 147-150 (2008)
|A Case of Hemolytic Anemia after Mitral Valve Repair
|A 43-year-old man was admitted for mitral valve repair. After quadrangular resection of the posterior leaflet, folding plasty was performed. Chordal reconstruction of the anterior leaflet was carried out and a 32-mm Cosgrove-Edwards ring was placed. Seven weeks after the operation, hemolytic anemia developed and serum lactate dehydrogenase elevated to 1,923IU/l. Doppler echocardiography showed only mild residual mitral regurgitation, but the regurgitation jet collided with the annuloplasty ring. The velocity of the regurgitation jet was 5.19m/s. After bisoprolol administration, the hemolytic anemia improved. However, the patient had been complaining of general fatigue; serum lactate dehydrogenase was found to be re-elevated after discharge despite the administration of bisoprolol. Therefore, re-operation was undertaken. The cause of the residual mitral regurgitation was mainly anterior leaflet prolapse. Chordal reconstruction and ring annuloplasty were re-performed. The hemolytic anemia was cured after re-operation. This case showed that a high-velocity regurgitation jet can cause hemolytic anemia, especially by colliding with an annuloplasty ring. It is important to accurately evaluate the severity, direction and velocity of the regurgitation jet by transesophageal echocardiography. It seems that the velocity of the regurgitation jet could become a parameter when deciding on the treatment plan.
Jpn. J. Cardiovasc. Surg. 37: 151-154 (2008)