Japanese Journal of Cardiovascular Surgery Vol.37, No.4

Originals

Prevalence ofDental Disease in Patients Undergoing Heart Valve Surgery 　　Y. Nakamura, et al.……213

Prevalence of Dental Disease in Patients Undergoing Heart Valve Surgery

(Department of Cardiovascular Surgery¹⁾ and Department of Dentistry and Oral Surgery²⁾, Kanto Medical Center NTT EC, Tokyo, Japan and Department of Cardiovascular Surgery, Tokyo Women’s Medical University Medical Center East³⁾, Tokyo, Japan)

Yoshitsugu Nakamura¹⁾ Osamu Tagusari¹⁾ Kenichi Saito²⁾

Shizu Oyamada¹⁾ Kentaro Honda¹⁾ Nobuyuki Homma¹⁾

Ryozo Miyamoto Kiyoharu Nakano³⁾

Bacteremia from dental disease is the most important cause of infective endocarditis in patients with heart valve disease. However, the prevalence of dental disease in patients undergoing valve surgery has not been clarified. One hundred thirty-seven patients had a dental check-up before heart valve surgery, 82 patients (59.9%) had significant dental disease which could have caused bacteremia. All patients with the dental disease underwent extraction preoperatively. There was neither complication in extraction nor any influence on heart valve surgery. Postoperative hospital stay was not prolonged due to the extraction. During the mean follow-up period of 30 months, no infective endocarditis was seen. The prevalence of dental disease was high in patients undergoing heart valve surgery. Preoperative treatment of dental disease did not have a negative impact on the postoperative course and hospital stay in heart valve surgery.
　Jpn. J. Cardiovasc. Surg. 37:213-216 (2008)

Case Reports

Two Cases of Double Orifice Repair for Congenital Mitral Regurgitation 　　N. Ishimoto, et al.……217

Two Cases of Double Orifice Repair for Congenital Mitral Regurgitation

(Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Gifu, Japan)

Naoyoshi Ishimoto Shuji Tamaki Yukifusa Yokoyama

Hiroshi Ishikawa Tomohiro Tsunekawa Motoshi Kozakai

We describe two cases of a 9-day-old male and a 5-year-10-month-old female who had congestive heart failure due to severe mitral regurgitation. Preoperative echocardiogram revealed severe mitral regurgitation due to dysplasia of the leaflet, chordae and papillary muscle. Because the leaflet area was not enough for the valve orifice, we performed double orifice repair by suturing the free edge to the corresponding edge of the opposite leaflet. The mitral regurgitation was found to be significantly reduced on postoperative echocardiogram. Double orifice repair is simple and can be performed rapidly. However, although this technique has been performed in adults, it has not been commonly performed in infants. Our results suggest that this procedure can be useful for the congenital mitral regurgitation. Long-term follow-up is needed to confirm the result.
　Jpn. J. Cardiovasc. Surg. 37: 217-220 (2008)

Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy in a Child 　　Y. Ban, et al.……221

Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy in a Child

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

Yukiko Ban* Yuji Hiramatsu Mio Noma

Hideyuki Kato Akihiko Ikeda Shinya Kanemoto

Masakazu Abe* Yuzuru Sakakibara

A 6-year-old boy who had been found to have hypertrophic obstructive cardiomyopathy presented with severely limited symptoms of heart failure due to progressive left ventricular outflow obstruction. Cardiac catheterization revealed the peak systolic pressure gradient of 87mmHg at left ventricular outflow, and systolic anterior motion of the anterior mitral leaflet with concomitant mitral regurgitation was observed by echocardiography. Transaortic septal myectomy was performed using transesophageal echocardiography guidance before, during and after surgery. Although the patient needed permanent pacemaker implantation for postoperative complete heart block, the procedure reduced the left ventricular outflow obstruction and relieved his symptoms.
　Jpn. J. Cardiovasc. Surg. 37: 221-225 (2008)

Infected Abdominal Aortic Aneurysm Rupture due to Listeria monocytogenes 　　K. Sakamoto, et al.……226

Infected Abdominal Aortic Aneurysm Rupture due to Listeria monocytogenes

(Division of Cardiovascular Surgery, Osaka Red Cross Hospital*, Osaka, Japan and Division of Cardiovascular Surgery, Hamamatsu Rosai Hospital**, Shizuoka, Japan)

Kazuhisa Sakamoto* Yoshitaka Hayashi* Tomofumi Taki*

Junichiro Nishizawa** Shogo Nakayama*

A76-year-old man was transferred to our hospital for evaluation of continuous abdominal pain with systemic inflammation. Clinical examinations suggested the pressure of an adynamic ileus due to diverculitis and an infrarenal abdominal aortic aneurysm. Thirty-eight millimeter in diameter despite the commencement of antibiotic therapy, the symptoms progressively worsened and repeated CT scan demonstrated a rupture of the aneurysm without any enlargement in diameter. An emergency operation was done, and the patient was discharged on the 77th postoperative day. Blood culture and histological findings disclosed an infected aortic aneurysm due to Listeria monocytogenes. The possibility of aortic infection should be considered in patients showing a sudden rupture of an aortic aneurysm.
　Jpn. J. Cardiovasc. Surg. 37: 226-229 (2008)

Aortic Valve Replacement in a Patient with Antiphospholipid Syndrome and Idiopathic Thrombocytopenic Purpura 　　Y. Yamamoto, et al.……230

Aortic Valve Replacement in a Patient with Antiphospholipid Syndrome and Idiopathic Thrombocytopenic Purpura

(Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan)

Yoshitaka Yamamoto Shigeyuki Tomita Hiroshi Nagamine

Syojiro Yamaguchi Koichi Higashidani Kenji Iino

Go Watanabe

A 66-year-old woman complained of dyspnea due to congestive heart failure, and was given a diagnosis of severe aortic insufficiency. Antiphospholipid syndrome and idiopathic thrombocytopenic purpura (ITP) had been diagnosed with 9 years previously. We planned preoperative plasma exchange and steroid pulse infusion to reduce the level of auto-antibodies for phospholipids. The aortic valve replacement was performed safely. Anticoagulant therapy with low molecular weight heparin and oral steroid therapy was administered after the operation to avoid thrombosis or bleeding. The patient’s postoperative course was stable. She was discharged without any complication. In conclusion, preoperative plasma exchange and steroid pulse infusion, postoperative anticoagulant therapy and oral steroids resulted in a favorable outcome in a case of heart surgery for a patient with antiphospholipid syndrome.
　Jpn. J. Cardiovasc. Surg. 37: 230-233 (2008)

Acute Type A Aortic Dissection Complicated with Acute Myocardial Infarction in a Case with an Aberrant Right Coronary Artery 　　K. Yamana, et al.……234

Acute Type A Aortic Dissection Complicated with Acute Myocardial Infarction in a Case with an Aberrant Right Coronary Artery

(Department of Cardiovascular Surgery, Komaki City Hospital, Komaki, Japan and Department of Cardiovascular Surgery, Nagoya University*, Nagoya, Japan)

Koji Yamana Masaru Sawazaki Shiro Tomari

Akihiko Usui* Yuichi Ueda*

Acute aortic dissection complicated with acute myocardial infarction in a case of 61-year-old woman with an aberrant right coronary artery was successfully treated by emergency operation fore type A acute aortic dissection. However, cardiogenic shock and bradycardia occurred after induction of anesthesia due to right ventricle myocardial ischemia. Cardiopulmonary bypass was established quickly and deep hypothermia was induced. We also perfused the right coronary artery with an external shunt tube to prevent the progression of the right ventricular infarction. The right coronary artery, which originated above the left coronary sinus, was dissected totally. We performed ascending and aortic arch replacement and coronary artery bypass grafting with a saphenous vein graft to the right coronary artery under hypothermic circulatory arrest. She had no major reduction of cardiac function. Although it was a rare combination, aberrant right coronary artery was vulnerable to myocardial ischemia associated with acute type A dissection. The external coronary shunt tube was useful for this type of myocardial ischemia.
　Jpn. J. Cardiovasc. Surg. 37: 234-236 (2008)

A Case of Heparin-Induced Thrombocytopenia (HIT) Diagnosed Which Waiting for Off-Pump Coronary Artery Bypass Grafting 　　K. Tanaka, et al.……237

A case of Heparin-Induced Thrombocytopenia (HIT) Diagnosed Which Waiting for Off-Pump Coronary Artery Bypass Grafting

(Department of Cardiovascular Surgery, Dokkyo Medical University Koshigaya hospital, Koshigaya, Japan)

Koyu Tanaka Soichi Shioguchi Shigeyoshi Gon

Yoshihito Irie Takao Imazeki

A 67-year-old man had angina pectoris due to left main trunk stenosis of coronary artery was transferred to our hospital. Anticoagulation was achieved with a continuous intravenous infusion of 625IU/h heparin. Sixteen days after admission, his platelet count decreased to 14×10⁴/μl, and further decreased to 9.1×10⁴/μl 4 days later. Since we suspected HIT, heparin administration was immediately discontinued, and was substituted with argatroban. A definitive diagnosis of type II HIT was made by a serologic test confirming positive antibodies to the heparin-platelet factor 4 (PF4) complexes. After the platelet count recovered, we performed off-pump CABG (OPCAB) using argatroban. The postoperative course was uneventful and platelet counts was normal. The patient was discharged on the 13th postoperative day. Heparin-induced thrombocytopenia, which causes thrombosis, is a serious side effect of heparin therapy. It is not rare, and in such case argatroban can be useful as an anticoagulant during OPCAB.
　Jpn. J. Cardiovasc. Surg. 37: 237-239 (2008)

Direct Implantation of the Left Coronary Artery to the Ascending Aorta in Bland-White-Garland Syndrome 　　M. Tateishi, et al.……240

Direct Implantation of the Left Coronary Artery to the Ascending Aorta in Bland-White-Garland Syndrome

(Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan)

Masaki Tateishi Tohru Takaseya Takemi Kawara

Shigemitsu Suzuki Yasuhisa Oishi Hiromichi Sonoda

Shigeki Morita

We herein describe the findings of a 32-year-old female was known to have had an electrocardiogram abnormalities and had avoided excessive exercise since her high school student days. She suddenly lost consciousness due to ventricular fibrillation (Vf) in July 2007. As a result she was taken to our hospital by ambulance. Emergency coronary angiography demonstrated an anomalous origin of the left coronary artery from the pulmonary artery (Bland-White-Garland Syndrome). She therefore underwent surgery. During the operation, the main pulmonary artery (PA) was transected while on the cardiopulmonary bypass and the left main coronary trunk (LMT) ostium was detected. Antegrade cold blood cardioplegia was induced, and retrograde continuous cold blood cardioplegia was subsequently applied to the coronary sinus, thus obtaining a complete cardiac standstill. The LMT ostium was excised with a cuff of the main PA wall as a button. During further dissection of the LMT distally to the bifurcation, the LMT wall was injured, thus resulting in the need to repair it under deep hypothermic circulatory arrest (DHCA) in order to obtain a bloodless surgical field. During core cooling, the LMT was anastomosed to the left posterolateral wall of the ascending aorta, then the LMT was repaired with a patch consisting of a non-treated autologous saphenous vein (SV) under DHCA. Several surgical techniques for BWG syndrome have been reported. Among these techniques, the direct implantation of the left coronary artery to the ascending aorta is the most physiological and therefore is considered to be the best technique. In this case, direct implantation was accomplished, however, the LMT also had to be repaired.
　Jpn. J. Cardiovasc. Surg. 37: 240-243 (2008)

A Penetrating Cardiac Injury by a Needle Which Was Buried in the Heart 　　K. Tamura, et al.……244

A Penetrating Cardiac Injury by a Needle Which Was Buried in the Heart

(Cardiac Center Sakakibara Hospital, Okayama, Japan and Department of Cardiovascular Surgery, Chugoku Rosai Hospital*, Kure, Japan)

Kentaro Tamura* Masahiko Kuinose Hidenori Yoshitaka

Yoshimasa Tsushima Hitoshi Minami Toshinori Totsugawa

Masamichi Ozawa

A-23-year-old man, with intellectual disability and history of self-inflicted injuries, presented with chest pain. A 3mm “picked” wound in the left chest was observed on physical examination. Chest computed tomography revealed a needle in the pericardium. Emergency surgery was performed by median sternotomy. At first we could not find the needle because it was completely buried in the heart, but when the posterior wall of the heart was exposed, the head of the needle appeared protruding from the posterior wall. It was removed and the wound of the posterior wall was closed with direct mattress sutures without cardio-pulmonary bypass. On inspection, the needle was 34mm long.
　Jpn. J. Cardiovasc. Surg. 37: 244-246 (2008)

Coarctation of the Aorta in an Adult Diagnosed by the Presence of Complete AV Block and Heart Failure 　　T. Miyauchi, et al.……247

Coarctation of the Aorta in an Adult Diagnosed by the Presence of Complete AV Block and Heart Failure

(General and Cardiothoracic surgery, Graduate School of Medicine, Gifu University, Gifu, Japan)

Tadamasa Miyauchi Katsuya Shimabukuro Eiji Murakami

Yukiomi Fukumoto Narihiro Ishida Toshiki Hatsune

Hideaki Manabe Hirofumi Takemura

A 51-year-old woman, who had been undergoing regular treatment and follow-up for hypertension since the age of 17, was diagnosed to have a patent ductus arteriosus (PDA) 6 months previously. On experiencing dyspnea, she visited the emergency room, where she was found to have a complete Atrioventricular (AV) Block and therefore was immediately admitted. The next day, she experienced acute heart failure requiring intubation. A DDD pacemaker was then implanted and the patient recovered thereafter. After recovery, a screening contrast-enhanced CT scan revealed coarctation of the thoracic aorta. The arterial pressure gradient between the arms and legs was about 70mmHg. The division of the PDA and the replacement of the coarcted aortic segment were performed under femoro-femoral cardiopulmonary bypass through a left posterolateral thoracotomy. The patient’s postoperative course was good, however, she complained of abdominal pain on the 6th postoperative day. An abdominal CT scan showed hemorrhage in the left rectus abdominus and right iliopsoas muscles. This improved after rest. No arterial pressure gradient was observed between the arms and the legs postoperatively. She was discharged on postoperative day 20. 　Because the average life expectancy of patients with untreated coarctation of the aorta has been reported to be about 34 years, it is recommended that surgical repair be performed as soon as possible. Patients with childhood-onset hypertension should therefore be evaluated to determine the primary disease whenever possible, such as coarctation of the aorta as in this case.
　Jpn. J. Cardiovasc. Surg. 37: 247-251 (2008)