Japanese Journal of Cardiovascular Surgery Vol.37, No.3

Originals

Strategy for Active Infective Native Valve Endocarditis and Tips on Mitral Valve Repair 　　M. Sawazaki, et al.……155

Strategy for Active Infective Native Valve Endocarditis and Tips on Mitral Valve Repair

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

Masaru Sawazaki Shiro Tomari Kohji Yamana

Our strategy for active infective native mitral valve endocarditis was to perform valve plasty after stabilizing the active endocarditis with antibiotics as much as possible. From 1997 through 2007, a consecutive series of 16 patients underwent mitral valve plasty for active infective native mitral valve endocarditis at our department. The purpose of this study was to retrospectively assess the clinical results. The mean age was 54.6±13.4 years, and 69% were men. Surgical indications were uncontrolled infection. The mean time between onset and diagnosis was 51.6±68.0 days, and that between diagnosis and operation was 35.8±15.2 days. Two patients were operated in the early phase because of uncontrolled sepsis. Operative and pathological findings revealed active infection in 14 patients (87.5%). However, there were some findings healing suggesting in the vegetations. According to the underlying lesion, mitral valve lesions were classified into 4 groups: anterior leaflet prolapse (3 patients), posterior leaflet prolapse (10 patients), commissural prolapse (2 patients) and non-prolapse (1 patient). We tried to remove or slice only vegetation, and we preserved adjacent leaflet tissue as much as possible. All mitral valve were successfully repaired. There was 1 (6.3%) operative death because of cerebral hemorrhage. The mean follow-up period of the surviving 15 patients was 4.2±2.9 years. There were no late deaths, no re-operations and no recurrence of moderate to severe mitral regurgitation. We conclude that a sufficient period of pre-operative antibiotic administration improves the prognosis, and our plastic technique of limited removal of the leaflet tissue was safe and effective.
　Jpn. J. Cardiovasc. Surg.37: 155-158 (2008)

Aortic Abdominal Aneurysm Repair in the Patients with Home Oxygen Therapy for 　Chronic Obstructive Pulmonary Disease 　　H. Minami, et al.……159

Aortic Abdominal Aneurysm Repair in the Patients with Home Oxygen Therapy for Chronic Obstructive Pulmonary Disease

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

Hiroya Minami Tatsuro Asada Kunio Gan

Takuya Misato Takashi Munezane

Between January and December 2006, 3 patients with aortic abdominal aneurysm (AAA) receiving home oxygen therapy (HOT) and 20 patients without HOT were studied. The 3 patients with HOT were all men, the mean age was 72 years (range, 69-74), and they had been treated with HOT for 37.3 months (1-102) due to chronic obstructive pulmonary disease (COPD) with a mean %VC of 96.9% and FEV1.0% of 42.8%. Only the FEV1.0% value in the preoperative data was significantly lower than in patients without HOT. In the 3 patients with HOT, extubation was performed immediately after operation, and minitracheotomy tubes (Mini-trach^®) to control sputum were inserted in the operation room. The minitracheotomy tubes were removed 5 or 6 days after operation. Postoperatively, no one with HOT had any major complications, while in those without HOT one patient had ileus and another had prolonged intubation. There were no significant differences between the 2 groups in operative time, blood loss, blood transfusion, or hospital stay. In conclusion, based on detached preoperative close estimation and careful postoperative supervision, patients receiving HOT can undergo AAA operations as safely as those not receiving HOT.
　Jpn. J. Cardiovasc. Surg. 37: 159-163 (2008)

Case Reports

Successful Operation for Multiple Giant Aneurysms with Congenital Coronary Artery 　Fistula in an Adult 　　T. Sasaki, et al.……164

Successful Operation for Multiple Giant Aneurysms with Congenital Coronary Artery Fistula in an Adult

(Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan)

Tomoyasu Sasaki Shintaro Nemoto Eiki Woo

Kan Hamori Masahiro Daimon Shigetoshi Mieno

Hideki Ozawa Keiichiro Kondo Takahiro Katsumata

We report a case of successful operation for multiple giant aneurysms with a right coronary artery fistula from the right coronary artery to the left atrium. A 35-years-old woman was found to have a right coronary artery aneurysm with a maximum diameter of 85mm, and two other coronary artery aneurysms with maximum diameters of 40 mm along the coronary fistula, which arose from the proximal right coronary artery, traversed the root of the left atrium, and drained into the left atrium. Surgical treatment was indicated to relieve symptoms and to prevent possible rupture of the aneurysms. She underwent resection of coronary artery aneurysms, closure of orifices of the fistula and coronary bypass grafting to the right coronary artery with cardiopulmonary bypass. Her postoperative course was uneventful, and she was discharged in good condition.
　Jpn. J. Cardiovasc. Surg. 37: 164-166 (2008)

Treatment for Ruptured Internal Iliac Artery Aneurysm with Concomitant 　Recto-Sigmoidal Resection 　　S. Fujii, et al.……167

Treatment for Ruptured Internal Iliac Artery Aneurysm with Concomitant Recto-Sigmoidal Resection

(Department of Cardiovascular Surgery and Department of Surgery*, Yokohama Sakae Kyousai Hospital, Yokohama, Japan)

Susumu Fujii Shigeharu Sawa Hiroshi Nagamine

Tohru Watanabe*

We describe a ruptured internal iliac artery aneurysm associated with sigmoid colon infarction. The patient was referred to our hospital complaining of lower abdominal pain. Computed tomography scan demonstrated a massive hematoma with a ruptured left internal iliac artery aneurysm. Hypovolemic shock prompted immediate laparotomy, endoaneurysmorrhaphy of the ruptured aneurysm, and resection of the recto-sigmoidal colon. During treatment for ruptured internal iliac aneurysm, we should consider potential colon infarction.
　Jpn. J. Cardiovasc. Surg. 37: 167-170 (2008)

Usefulness of Osler’s Node Skin Findings in the Diagnosis of Left Atrial Infective 　Endocarditis 　　M. Sakaguchi, et al.……171

Usefulness of Osler’s Node Skin Findings in the Diagnosis of Left Atrial Infective Endocarditis

(Department of Cardiovascular Surgery, Saga Prefectural Hospital Koseikan, Saga, Japan)

Masayuki Sakaguchi Hitoshi Ohteki Kozo Naitoh

Hiroumi Kataoka Takeshi Hakuba

A 26-year-old woman was referred to our hospital with a high fever and thrombocytopenia. The patient was initially given a diagnosis of disseminated intravascular coagulopathy and sepsis. Medial therapy with antibiotic and anticoagulative drug was started in the Department of Internal Medicine. After that, dermatologists identified painful nodular erythema on the face and extremities as Osler’s nodes. Echocardiogram revealed a vegetation near the annulus of the mitral valve. The urgent operation was performed. Intraoperative findings showed vegetation on the posterior wall of the left atrium and normal mitral valves. Therefore, vegetation was completely excised with the diseased left atrial wall and the mitral valve was preserved. The defect of the atrial wall was repaired with a pericardial patch. Methicillin-resistant Staphylococcus aureus was detected by blood and tissue bacterial culture. Postoperative echocardiograms showed mild mitral regurgitation. The patient was discharged from hospital after an uneventful postoperative course.
　Jpn. J. Cardiovasc. Surg. 37: 171-173 (2008)

Tuberculous Mycotic Pseudoaneurysm of the Abdominal Aorta 　　Y. Akiyama and K. Matsubara……174

Tuberculous Mycotic Pseudoaneurysm of the Abdominal Aorta

(The Department of Surgery, Tachikawa Hospital, Tachikawa, Japan)

Yoshinobu Akiyama Kentaro Matsubara

A 54-year-old man with a sacral abdominal aortic aneurysm (4cm) complained of lower abdominal pain. An abdominal computed tomographic (CT) scan revealed a 1cm expansion in 2 weeks. The abdominal aorta was replaced with an in situ expanded polytetrafluoroethylene graft. Granulomatous lymphoadenitis was diagnosed in the aneurysm wall by histological examination. The patient’s postoperative course was uneventful, and anti-tuberculosis medical drug therapy was given for 6 months.
　Jpn. J. Cardiovasc. Surg. 37: 174-176 (2008)

A Case of Femoro-Iliac Cross-Over Vein Bypass with a Ringed ePTFE Graft for Common 　Iliac Venous Thrombosis 　　Y. Iida, et al.……177

A Case of Femoro-Iliac Cross-Over Vein Bypass with a Ringed ePTFE Graft for Common Iliac Venous Thrombosis

(Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Japan)

Yasunori Iida Kazuo Yamamoto Takehito Mishima

Akifumi Uehara Kenji Sakakibara Tsutomu Sugimoto

Shinpei Yoshii Shigetaka Kasuya

A 71-year-old man had sudden onset of left lower limb swelling and consulted an orthopedic surgeon 14 days later. Venous echography demonstrated compression of the left iliac vein and the thrombus of the common iliac vein. After emergency admission, conservative therapy was given for 7 days, but the symptoms did not sufficiently diminish and a thrombus was also present. We therefore performed femoro-iliac cross-over vein bypass using a 10mm ringed ePTFE graft. Symptoms were completely improved and the graft was shown to be patent by echography after 3 months.
　Jpn. J. Cardiovasc. Surg. 37:177-180 (2008)

A Case of Giant Aortic Abdominal Aneurysm with Symptoms of Duodenal Obstruction 　　M. Nakashima, et al.……181

A Case of Giant Aortic Abdominal Aneurysm with Symptoms of Duodenal Obstruction

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

Masaya Nakashima Shin Morita Katsuhito Teranishi

Kazuo Yamaguchi Eiji Takeuchi

A 66-year-old man had presented with nausea and vomiting at a neighboring hospital. Abdominal CT scan revealed a giant aortic abdominal aneurysm accompanied by duodenal obstruction. Y-graft replacement operation was performed in our hospital. Although aortic abdominal aneurysm is often unexpectedly diagnosed by abdominal CT scan, very few cases of aortic abdominal aneurysm have been diagnosed in association with ileac abdominal symptoms; for example vomiting and abdominal pain. We report a case of giant aortic abdominal aneurysm with symptoms of duodenal obstruction, describing pathophysiologic aspects.
　Jpn. J. Cardiovasc. Surg. 37: 181-184 (2008)

Hybrid Endovascular Stent Graft Repair with Reconstruction of Superior Mesenteric and 　Celiac Arteries for a Ruptured Thoracoabdominal Aortic Aneurysm 　　D. Yotsumoto, et al.……185

Hybrid Endovascular Stent Graft Repair with Reconstruction of Superior Mesenteric and Celiac Arteries for a Ruptured Thoracoabdominal Aortic Aneurysm

(Thoracic and Cardiovascular Surgery, Hepato-Biliary-Pancreatic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan)

Daisuke Yotsumoto Yoshifumi Iguro Hiroyuki Yamamoto

Kazuhisa Matsumoto Ryuzo Sakata

A 77-year-old woman was referred to our hospital for treatment of a ruptured thoracoabdominal aortic aneurysm (TAAA) with a maximum diameter of 7cm. Considering her age and level of daily activity, the placement of an endovascular stent graft was performed as an emergency rescue procedure. For termination of the endoleak from the distal portion of the stent graft detected by CT the next day, another stent graft placement was added after establishment of blood supply to the superior mesenteric and celiac arteries by placing a Y-shaped graft from the abdominal aorta to each artery with success. The patient was discharged from our hospital 25days after surgery with disappearance of endoleak and good graft patency. A hybrid technique with grafting to abdominal branches, followed by placement of stent graft, can be an alternative treatment for such high-risk patients with ruptured TAAA.
　Jpn. J. Cardiovasc. Surg. 37: 185-188 (2008)

Successful Surgical Correction of Incomplete Atrioventricular Septal Defect in a 72-Year-Old 　Female Patient 　　H. Yanagi, et al.……189

Successful Surgical Correction of Incomplete Atrioventricular Septal Defect in a 72-Year-Old Female Patient

(Department of Cardiovascular Surgery, Yokohama Municipal Citizen Hospital, Yokohama, Japan and International University of Health and Welfare*, Atami, Japan)

Hiromasa Yanagi Yasuko Uranaka Yoshinori Takanashi*

We describe surgical repair of an incomplete atrioventricular septal defect (AVSD) in a 72-year-old woman who had cerebral infarction and severe congestive heart failure. A massive left-to-right shunt and severe left atrioventricular valve regurgitation, associated with pulmonary hypertension, were found on transesophageal echocardiography and cardiac catheterization. She underwent complete closure of the cleft and patch closure of the ostium primum defect. We conclude that surgical correction should be considered even in elderly patients with incomplete AVSD.
　Jpn. J. Cardiovasc. Surg. 37: 189-192 (2008)

A Surgically Treated Case of Subepicardial Aneurysm of the Right Ventricle 　　M. Ozawa, et al.……193

A Surgically Treated Case of Subepicardial Aneurysm of the Right Ventricle

(The Sakakibara Heart Institute of Okayama, Okayama, Japan and Bordeaux UniversityII, Haut-Leveque Cardiologic Hospital＊, Bordeaux, France)

Masamichi Ozawa Masahiko Kuinose Hidenori Yoshitaka

Kentaro Tamura* Dai Une

A 76-year-old woman who had undergone 5 surgical procedures and chemotherapy for retro-peritoneal liposarcoma was found to have a right ventricular aneurysm by echocardiography, magnetic resonance imaging (MRI) and right ventricular cineangiogram. We decided that it was a false aneurysm because of communication with the right ventricle through a small orifice. At operation, aneurysm was not strongly adherent, so we closed the small orifice with a purse-string suture, and covered it with part of the wall of the aneurysm. Subepicardial aneurysm of the right ventricle was diagnosed by operative and pathological findings. The postoperative course was uneventful and she was discharged on the 15th postoperative day.
　Jpn. J. Cardiovasc. Surg. 37: 193-196 (2008)

A Case of Left Ventricular Plasty (SAVE Operation) for a Ventricular Septal 　Perforation and a Left Ventricular Aneurysm Associated with Acute Myocardial 　Infarction 　　Y. Hisata, et al.……197

A Case of Left Ventricular Plasty (SAVE Operation) for a Ventricular Septal Perforation and a Left Ventricular Aneurysm Associated with Acute Myocardial Infarction

(Division of Cardiovascular Surgery, Sasebo City General Hospital, Sasebo, Japan and Division of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan)

Yoichi Hisata Shiro Hazama Kenta Izumi

Kiyoyuki Eishi*

A 71-year-old man with obstruction of the left anterior descending branch (＃7) suffered an acute myocardial infarction. A ventricular septal perforation (VSP) and a widespread left ventricular aneurysm were detected in the anteroseptal region by both cardiac ultrasonography and cardiac catheterization. Surgery was performed at week 7 after onset. After establishing extracorporeal circulation, the left ventricular aneurysm was longitudinally excised from the left side of the left anterior descending branch while the patient was maintained in a state of cardiac arrest. A septal anterior ventricular exclusion (SAVE) operation was performed using oblong equine pericardial patches to exclude the left ventricular aneurysm and the VSP portion. The VSP was directly closed with sutures because the surrounding tissues were relatively strong at week 7 after the onset of the myocardial infarction and the portion was excluded with an equine pericardial patch. At the same time, CABG (LITA-LAD) was also performed. After surgery, left ventriculography found no residual shunts and we were able to obtain both a good morphology and satisfactory functioning of the left ventricle. The present method is thus considered to be an effective surgical method that excludes both the VSP portion and the infracted portion, while improving the morphology of the left ventricle for VSP with a left ventricular aneurysm.
　Jpn. J. Cardiovasc. Surg. 37: 197-200 (2008)

A Case of Postoperative Paraplegia following Elective Surgery for Aneurysm of the 　Abdominal Aorta 　　S. Fukuda, et al.……201

A Case of Postoperative Paraplegia following Elective Surgery for Aneurysm of the Abdominal Aorta

(Department of Cardiovascular Surgery* and Department of Critical Care**, Mitsui Memorial Hospital, Tokyo, Japan)

Sachito Fukuda*.** Ikutaro Kigawa* Yujiro Miura*

Takeshi Miyairi*

This report documents two rare cases we encountered in which paraplegia developed as a postoperative complication following elective operations for an unruptured abdominal aortic aneurysm (AAA). Case1: A 80-year-old man receiving dialysis therapy was found to have 75% occlusion of the left anterior descending branch by preoperative coronary arteriography but, as the cardiac function was satisfactory, replacement of the aneurysm with a tube graft was performed through a retroperitoneal approach for treatment of the AAA. Symptoms of paraplegia developed immediately following the operation and a diagnosis of anterior spinal artery syndrome was made based on the postoperative MRI findings. Case 2: A 62-year-old man underwent a coronary artery bypass operation (3 sites in 2 branches) using the bilateral internal thoracic artery with the breast beating prior to elective surgery for an unruptured AAA, and subsequently underwent an aneurysm replacement with a Y-graft through a midline incision. At the same time, the celiac artery and superior mesenteric artery cure found to be stenotic at their roots were also bypassed via vascular prostheses to the right arm of the Y-graft. Paraplegia was evident after emerging from anesthesia. In both cases, there were complicating coronary arterial lesions and significant atherosclerotic changes in the thoracic descending aorta. A CT scan demonstrated an artery coursing from the iliolumbar artery, a branch of the internal iliac artery, to the spinal cord in Case 2, indicating that intraoperative clamping of the internal iliac artery might have caused the paraplegia. In patients with marked arteriosclerosis of the thoracic descending aorta, there is the possibility of occlusion of spinal root arteries originating from that affected region. Blood supply to the spinal cord via a collateral vascular route is important in such cases.
　Jpn. J. Cardiovasc. Surg. 37: 201-204 (2008)

A Successful Case of Redo Off-Pump Coronary Artery Bypass Grafting through a Left 　Thoracotomy Using PAS・Port System for Proximal Vein Graft Anastomoses 　　S. Mochizuki, et al.……205

A Successful Case of Redo Off-Pump Coronary Artery Bypass Grafting through a Left Thoracotomy Using PAS・Port System for Proximal Vein Graft Anastomoses

(Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi, Japan)

Shingo Mochizuki Tatsuya Nakao Norifumi Shigemoto

Yasushi Kawaue

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS・Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS・Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.
　Jpn. J. Cardiovasc. Surg. 37: 205-208 (2008)

Repair of Recurrent Congenital Mitral Insufficiency Using Folding Plasty 　　K. Koizumi, et al.……209

Repair of Recurrent Congenital Mitral Insufficiency Using Folding Plasty

(Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan and Department of Pediatric Cardiac Surgery, Saitama Medical University International Medical Center*, Hidaka, Japan)

Kiyoshi Koizumi Toshihiko Ueda Shinichi Taguchi

Yoshito Inoue Ichiro Kashima Toshiyuki Katogi*

A 13-year-old girl with congenital mitral incompetence had undergone valvoplasty using the De Vega technique at age 5. The patient was referred by the pediatric department due to recurrence of mitral incompetence. Transesophageal echocardiography indicated regurgitation from A2 and P3, mild mitral leaflet tethering and left ventricular dilatation. Intraoperative findings showed valvular agenesis of the posterior leaflet around P3. No leaflet prolapse was observed at A2, but leaflet P2 had fallen to the left ventricular side compared with leaflet A2, thereby inducing regurgitation due to coaptation gap. In a procedure similar to folding plasty, leaflet P3 was folded down and sutured to the annulus extending up to the posteromedial commissure. This technique not only controlled regurgitation at P3 but also improved the coaptation between A2 and P2. Annuloplasty was conducted using a 28-mm Physio-ring. Folding plasty may be an effective surgical option for patients with congenital mitral incompetence because a broad valve orifice area can be maintained because there is no need for annular plication.
　Jpn. J. Cardiovasc. Surg. 37: 209-211 (2008)