Japanese Journal of Cardiovascular Surgery Vol.37, No.5

Original

Initial Evaluation of Endoscopic Saphenous Vein Harvesting 　　S. Matsuyama et al.……255

Initial Evaluation of Endoscopic Saphenous Vein Harvesting

(Division of Cardiovascular Surgery, Nagasaki Kouseikai Hospital, Nagasaki, Japan and Sakakibara Heart Institute, Division of Cardiovascular Surgery*, Fuchu, Tokyo, Japan)

Shigefumi Matsuyama* Etsuro Suenaga Manabu Sato

Shugo Koga

In this report, we present our initial experience of endoscopic saphenous vein harvesting (ESVH) using the Vasoview System. ESVH was performed in 72 patients between May 2006 and October 2007. The mean patient age was 73±6.7 years, and 54 (75%) were men. The success rate of ESVH was 98.6% (71/72). The mean harvest time was 36±11 min. The mean number of side branches requiring repair was 1.19±1.21. Comparing the first 5 cases with the last 5 cases, the time for harvesting time and the number of repaired branches improved significantly. Wound complications occurred in 2 patients (2.7%) postoperatively. The intraoperative mean graft flow was 25±13 ml/min. The early patency was 87% (47/54) as evaluated by postoperative angiography or CT. The intraoperative graft flow and early patency were satisfactory. ESVH is easy to adopt and has excellent cosmetic advantages.
　Jpn. J. Cardiovasc. Surg. 37: 255-258 (2008)

Case Reports

Coronary Artery Bypass Grafting in a Patient with Malignant Rheumatoid Arthritis 　　T. Choh et al.……259

Coronary Artery Bypass Grafting in a Patient with Malignant Rheumatoid Arthritis

(Department of Cardiovascular Surgery, Yokohama City University, Yokohama, Japan and Yokohama City University Medical Center*, Yokohama, Japan)

Tomoki Choh Kiyotaka Imoto* Shinichi Suzuki

Keiji Uchida* Hiromasa Yanagi* Kensuke Kobayashi*

Kouichirou Date* Motohiko Gouda* Munetaka Masuda

The patient was a 39-year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5, 99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery（segment 5, 100%), circumflex artery (segment 11, 99%), and right coronary artery (segment 1, 90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.
　Jpn. J. Cardiovasc. Surg. 37: 259-263 (2008)

Congenital Coronary Artery Fistula Associated with Infective Endocarditis of the Mitral Valve 　　M. Ohno et al.……264

Congenital Coronary Artery Fistula Associated with Infective Endocarditis of the Mitral Valve

(Department of Cardiovascular Surgery, Showa University, Tokyo, Japan)

Masahiro Ohno Tadashi Omoto Makoto Mohri

Masaomi Fukuzumi Masaya Ohi Takahisa Okayama

Noboru Ishikawa Takeo Tedoriya

A 54-year-old woman complained of prolonged fever. Echocardiography showed severe mitral regurgitation with vegetation, and computed tomography showed right coronary artery (RCA) fistula to the coronary sinus (CS). Blood culture revealed Strep. viridans, thus a diagnosis of active infective endocarditis was established. The patient underwent urgent surgery. Surgical findings showed that vegetation was located in A3 to P3 of the mitral valve. The patient underwent mitral valve repair using a glutalualdehyde-treated autologous pericardial patch and artificial chordea. Epicardial ligation for fistula was performed. Her postoperative course was uneventful.
　Jpn. J. Cardiovasc. Surg. 37: 264-267 (2008)

A Case of Surgical Treatment for Pseudoaneurysm 19 Years after Aortic Root Replacement 　　M. Kabasawa et al.……268

A Case of Surgical Treatment for Pseudoaneurysm 19 Years after Aortic Root Replacement

(Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Chiba, Japan)

Masashi Kabasawa Yoshiharu Takahara Kenji Mogi

Masaharu Hatakeyama

We report a case of surgical treatment for pseudoaneurysm 19 years after aortic root replacement. The patient was a 57-year-old female who had undergone aortic root replacement (Piehler procedure) in another hospital due to acute Stanford A type aortic dissection in 1988, and was then followed up at another hospital. However, a low density area around the artificial graft was pointed out on computed tomography (CT) in 2001, which increased to 60mm in size by November, 2006. She was then referred to our hospital for a redo operation. Pseudoaneurysm of the anastomosis and mitral regurgitation (MR) was diagnosed by the examination of the CT, angiography, etc., and we performed ascending aorta and aortic arch replacement, and mitral valve replacement (MVR) in April, 2007. A slight hemorrhage were found at the anastomosis of the artificial graft-artificial graft. Deterioration of the artificial graft or deterioration of the suture was suspected as the cause of the slight hemorrhage from the anastomosis a long period after the operation. In this case, loosening of the suture string was revealed, so the latter was more strongly suspected.
　Jpn. J. Cardiovasc. Surg. 37: 268-271 (2008)

A Case of Lipoma in the Right Atrium with Bilateral Leg Edema 　　T. Sakamoto et al.……272

A Case of Lipoma in the Right Atrium with Bilateral Leg Edema

(Department of Cardiovascular Surgery, Kinan Hospital, Tanabe, Japan)

Tomohiko Sakamoto Yasuhisa Shimazaki Keiji Iwata

An 80-year-old man complained of bilateral leg edema. Doppler echocardiography showed a mobile tumor (33mm) in the right atrium and severe tricuspid regurgitation with an atrial fibrillation. An operation was performed urgently. Excision of the tumor including the right atrial wall and tricuspid annuloplasty were done. Histologic study demonstrated lipoma and no malignancy. Bilateral leg edema disappeared, and the sinus rhythm was restored after the operation.
　Jpn. J. Cardiovasc. Surg. 37: 272-275 (2008)

Endovascular Treatment for Ruptured Infected Descending Thoracic Aortic Aneurysm 　　A. Aoki and K. Sangawa……276

Endovascular Treatment for Ruptured Infected Descending Thoracic Aortic Aneurysm

(Department of Cardiovascular Surgery, Matsuyama Shimin Hospital and present address: Department of Cardiovascular Surgery, Kagawa Central Hospital*, Takamatsu, Japan)

Atsushi Aoki* Kenji Sangawa

Endovascular treatment with a hand-made stent graft was performed successfully for a ruptured infected descending thoracic aortic aneurysm in the patient under chronic hemodialysis. The patient was a 77-year-old man and hemodialysis was continued with a double lumen catheter because of internal shunt occlusion since November 2005. He developed MRSA sepsis around January 2006 and was treated with antibiotics. Left pleural effusion was drained on March 1st, 2006. Initially left effusion from the left side was fluently bloody, however it became bloody the next day. Enhanced CT revealed the descending thoracic aortic aneurysm and left hemo-thorax. He was referred to our service, and was transportedly via ambulance. Home made stent graft was deployed under local anesthesia 2h after the arrival. His hemodynamic status became stable and left pleural hematoma was removed by video assisted thoracic surgery 2 days after endovascular treatment. His postoperative course was uneventful and antibiotics were continued 4 weeks. He is doing well without any recurrence of infection 23 month after the surgery. Careful follow up is mandatory, and endovascular treatment would be useful for the ruptured infected aortic aneurysm.
　Jpn. J. Cardiovasc. Surg. 37: 276-280 (2008)

Successful Off-Pump Coronary Artery Bypass Grafting for a Renal Transplant Patient 　　Y. Hayashida et al.……281

Successful Off-Pump Coronary Artery Bypass Grafting for a Renal Transplant Patient

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

Yoshio Hayashida Noritsugu Morishige Hidehiko Iwahashi

Masaru Nishimi Kazuma Takeuchi Nobuhisa Ito

Go Kuwahara Yuta Sukehiro Tadashi Tashiro

This paper reports the findings of off-pump coronary artery bypass grafting (OPCAB) for a 56-year-old man who had undergone a renal transplantation. Coronary angiography (CAG) revealed triple-vessel coronary disease. OPCAB was therefore performed. The patient was discharged 20 days after surgery without any subsequent rejection, infection or renal dysfunction. At two years after the operation the patient is doing well without any cardiac events. Cardiac disease, especially coronary artery disease is a common cause of death in renal transplant patients. Cardiac surgery in renal transplant patients is expected to increase. OPCAB for renal transplant patients with ischemic heart disease is therefore expected to reduce the incidence of myocardial infarction, thereby prolonging patient survival.
　Jpn. J. Cardiovasc. Surg. 37: 281-284 (2008)

Infective Endocarditis Followed by Mycotic Aneurysm of the Ulnar Artery 　　T. Ishikawa et al.……285

Infective Endocarditis Followed by Mycotic Aneurysm of the Ulnar Artery

(Department of Cardiovascular Surgery, Bell Land General Hospital, Osaka, Japan)

Takumi Ishikawa Katsuaki Hige Takanobu Aoyama

We present a surgical case of mycotic aneurysm of the ulnar artery occurring 2 months after surgical treatment for infective endocarditis (IE). A 59-year-old man was referred to our hospital because of dyspnea and fever. An echocardiogram showed severe mitral regurgitation with vegetations. Blood culture disclosed Methicillin-resistant Coagulase Negative Staphylococcus (MRCNS), and brain computed tomography (CT) demonstrated an intracranial hemorrhage in the right posterior lobe. After one month of antibiotic treatment, mitral valve replacement (MVR) was performed successfully. Antibiotic treatment was continued postoperatively for 4 weeks; the C-reactive protein (CRP) level and peripheral white blood cell count were reduced to the normal range. Two months after MVR, a pulsatile mass rapidly increasing in size was seen in his right forearm. Contrast-enhanced CT showed aneurysm formation in his right ulnar artery. The aneurysm was managed by excision, and the brachial artery was reconstructed with a reversed saphenous vein graft. It is essential when observing the course of IE patients to bear in mind at all times that a healed mycotic aneurysm might increase in size.
　Jpn. J. Cardiovasc. Surg. 37: 285-287 (2008)

Acute Aortic Dissection with Rhabdomyolysis 　　K. Hisatomi et al.……288

Acute Aortic Dissection with Rhabdomyolysis

(Department of Cardiovascular Surgery, Nagasaki Medical Center, Omura, Japan)

Kazuki Hisatomi Seiji Matsukuma Hiroshi Yamaguchi

Masayoshi Hamawaki

Acute aortic dissection causes various complications, but rarely causes rhabdomyolysis before the operation. A 69-year-old woman was found to have fallen unconscious and was transported to our hospital. Chest contrast computed tomography revealed thrombosed type A acute aortic dissection. On admission, hypoxia with paradoxical breathing was recognized and she complained of chest and back pain, and severe leg pain. In blood examination, elevation of myogenic enzymes and acute renal dysfunction were recognized. However computed tomography showed no signs of the ischemia of the intraperitoneal organs and legs. Myogenic enzymes decreased gradually and acute renal dysfunction improved by conservative therapy. In spite of strict antihypertensive therapy, enlargement of the false lumen and re-dissection were occurred, for this reason we scheduled ascending aorta replacement. During the operation we did muscle biopsy, and myogenic changes, such as cytolysis and lymphocyte infiltration, were recognized in muscles pathologically. However all various autologous antibody examinations were negative. We concluded that rhabdomyolysis was due to transient shock and caused preoperative marked elevation of myogenic enzymes.
　Jpn. J. Cardiovasc. Surg. 37: 288-290 (2008)

Anterolateral Right Thoracotomy for Mitral Valve Replacement for Treating Infectious Endocarditis in a Case with Esophagus Reconstructed by Presternal Colonic Interposition for Previous Esophagogastrectomy 　　Y. Kawase et al.…291

Anterolateral Right Thoracotomy for Mitral Valve Replacement for Treating Infectious Endocarditis in a Case with Esophagus Reconstructed by Presternal Colonic Interposition for Previous Esophagogastrectomy (Department of Cardiovascular Surgery, Chigasaki Tokushukai General Hospital, Chigasaki, Japan and General and Cardiovasc Surgery, Kanazawa University*, Kanazawa, Japan) Yushi Kawase Go Watanabe* A case of infectious endocarditis was surgically treated by mitral valve replacement. The patient had previously undergone presternal subcutaneous colonic interposition as reconstruction surgery due to esophageal and gastric cancer. This artificial esophagus prevented the central sternotomy that is necessary for cardiac surgery. In cases where sternotomy is difficult, anterolateral right intercostal thoracotomy is useful. Arterial cannulation was performed via the femoral artery; cannulations for venous drainage were performed in the femoral vein for the inferior vena cava and in the right jugular vein for the superior vena cava in order to establish cardiopulmonary bypass circulation. Under the condition of ventricular fibrillation and a body temperature of 25℃, the mitral valve that had been destroyed by infection was resected by exposure of the left atrium on its right side. An artificial Saint Jude Medical mechanical valve, 29mm in diameter, was implanted. The thorax was insufflated with carbon dioxide gas to prevent air embolization. An aortic vent tube was used for air drainage from the cardiac output. Although a seizure occurred once after the operation, the post-operative course was very stable; currently, the patient (NYHAⅠ) is in very good condition with no recurrence of the cancer. Jpn. J. Cardiovasc. Surg. 37: 291-294 (2008)

A Surgical Case of Aortic Intramural Hematoma in the Presence of Coexisting Ascending Aortic Aneurysm 　　Y. Tamiya et al.…295

A Surgical Case of Aortic Intramural Hematoma in the Presence of Coexisting Ascending Aortic Aneurysm

(Department of Cardiovascular Surgery, Otaru Municipal Second Hospital, Otaru, Japan)

Yukihiko Tamiya Johji Fukada Yasuaki Fuzisawa

An 82-year-old woman was given emergency admission because of severe anterior chest pain. We found an ascending aortic aneurysm 60mm in diameter. CT revealed acute aortic dissection with an ascending aorta. Emergeny operation was performed under a diagnosis of type-A acute aortic dissection with ascending aortic aneurysm. Operative findings showed thrombus in the dissection and a dilated ascending aorta without intimal tears. Operative findings differed from those of a classical dissection and were compatible with a diagnosis of aortic intramural hematoma (IMH). We performed hemi-arch replacement for the ascending aortic aneurysm under deep hypothermic cardiac arrest and she was discharged without any complications. IMH in the presence of coexisting ascending aortic aneurysm is extremely rare and we therefore reported the surgical repair of this rare case.
　Jpn. J. Cardiovasc. Surg. 37: 295-297 (2008)

Successfully Treated Secondary Aorto or Iliac Arterial-Enteric Fistula 　　K. Ishikawa et al.……298

Successfully Treated Secondary Aorto or Iliac Arterial-Enteric Fistula

(Department of Cardiovascular Surgery and Department of Pediatric Cardiovascular Surgery*, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan)

Kazunori Ishikawa Hirofumi Midorikawa Megumu Kanno

Takashi Ono* Shigehiro Morishima*

We here report two cases of successfully treated secondary aorto or iliac arterial-enteric fistula after graft replacement for abdominal aortic aneurysm. Case 1: A 80-year-old man who complained massive anal bleeding had undergone Y-shaped graft replacement for abdominal aortic aneurysm 22 years previously. Computed tomography demonstrated an aneurysm and hematoma formation at the anastomosis of the right graft limb and the right common iliac artery. Preoperative angiography showed no leak of contrast medium at the distal anastomosis of the right graft limb. A presumptive diagnosis of secondary iliac arterial enteric fistula was made, therefore, we performed an emergency operation. Extra-anatomic bypass preceded the removal of the right graft limb, partial resection and direct reconstruction of the ileum by the retroperitoneal approach. His postoperative course was uneventful and he was discharged on the 19th postoperative day. Case 2: A 77-year-old man who had received Y-shaped graft replacement of an abdominal aortic aneurysm 9 years previously was transferred to our hospital because of sudden onset epigastralgia and massive hematemesis. Gastroduodenoscopy revealed a fresh blood clot in the third portion of the duodenum where it was compressed by for surrounding pulsatile environment. An emergency computed tomography showed aneurysm formation without extravasation of contrast medium in the duodenum at the proximal anastomosis of the prosthetic graft. A secondary aortoenteric fistula was highly suspected and emergency operation was performed. Extra-anatomic bypass preceded the removal of the graft body, infrarenal aortic stump closure, duodenal closure and the greater omentum was used to fill defects. He underwent successful staged abdominal wall closure due to bowel edema making primary closure impossible. His postoperative course was uneventful and he was discharged on the 26th postoperative day.
　Jpn. J. Cardiovasc. Surg. 37: 298-301 (2008)

Successful Two-Staged Surgical Treatment for a Thoracoabdominal Aortic Aneurysm Combined with an Aberrant Right Subclavian Artery, Kommerell’s Diverticulum, and Angina Pectoris 　　Y. Iida et al.……302

Successful Two-Staged Surgical Treatment for a Thoracoabdominal Aortic Aneurysm Combined with an Aberrant Right Subclavian Artery, Kommerell’s Diverticulum, and Angina Pectoris

(Department of Vascular Surgery, Tokyo Medical University, Tokyo, Japan)

Yasunori Iida Yukio Obitsu Naozumi Saiki

Nobusato Koizumi Hiroshi Shigematsu

A 72-year-old man with a thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery, Kommerell’s diverticulum, and angina pectoris during follow-up for peripheral arterial disease was successfully treated surgically by two-staged operation. First, we performed total arch replacement using cardiopulmonary bypass, systemic hypothermia, selective cerebral perfusion, and coronary artery bypass grafting. Secondly, we performed replacement of the thoracoabdominal aortic aneurysm using a partial cardiopulmonary bypass. The postoperative course was uneventful. This is apparently the first case of repair for the thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery and Kommerell’s diverticulum.
　Jpn. J. Cardiovasc. Surg. 37: 302-305 (2008)

Surgical Treatment for an Intracardiac Needle-Like Foreign Body 　　E. Nakamura et al.……306

Surgical Treatment for an Intracardiac Needle-Like Foreign Body

(Department of Cardio-Vascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan and Kuwabara Clinic*, Miyazaki, Japan)

Eisaku Nakamura Kunihide Nakamura Masachika Kuwabara*

Masakazu Matsuyama Katsuhiko Niina Hirohito Ishii

A 37-year-old man who had suffered right chest pain while mowing weeds was transferred to our hospital. A chest roentgenogram revealed a needle-like foreign body overlying the cardiac silhouette and chest CT confirmed an intracardiac foreign body. The patient underwent emergency operation, and a foreign body was removed under cardiopulmonary bypass and performed cardiac repair. A foreign body penetrated right lung and reached it in the left atrial cavity. The patient recovered uneventfully without any symptoms of infections.
　Jpn. J. Cardiovasc. Surg. 37: 306-309 (2008)