Japanese Journal of Cardiovascular Surgery Vol.37, No.6

Originals

Risk Assessment for a Learning Curve in Endovascular Abdominal Aortic Aneurysm Repair with the Zenith Stent-Graft 　　T. Azuma et al.……311

Risk Assessment for a Learning Curve in Endovascular Abdominal Aortic Aneurysm Repair with the Zenith Stent-Graft: The First Year in Japan

(Department of Cardiovascular Surgery, Tokyo Women’s Medical University*, Tokyo, Japan and Department of Vascular Surgery, Tokyo Medical University* Tokyo, Japan)

Takashi Azuma*,** Satoshi Kawaguchi** Taro Shimazaki**

Kenji Koide** Masataka Matsumoto** Hiroshi Shigematsu**

Akihiko Kawai* and Hiromi Kurosawa*

In Japan, doctors inexperienced stent-graft new devices are required to secure agreement on criteria and choice of the device size in endovascular aneurysm repair (EVAR) from experienced doctors. It was hoped that strict patient selection might reduce the learning curve for initial successes in given procedures. In a leading center in Japan, a number of cases which were scheduled for operation at other institutes were evaluated anatomically. We surveyed the initial success of Zenith AAA system implantation in the remaining cases by inexperienced doctors and evaluated the results. This study aimed to verify the validity of strict patient selection in improving the success rate of inexperienced doctors. We enrolled 112 consecutive patients from 19 institutes, who were scheduled for repair between January and October in 2007. All patients were evaluated on the basis of a less-than-3mm reconstructed CT image. Mean patient age was 76±5.7 years. All cases satisfied the Zenith’s anatomic prerequisites. Fifteen cases were excluded for various reasons, the major reason being insufficiency of the proximal landing zone (LZ) length, angle and contour. The second reason was difficulty to approach via the iliac artery. Ninety seven cases were included, of which 17 cases were low-risk candidates for EVAR. Medium-risk seventy two cases requiring some advice to avoid problems with device size, technique of implantation and choice of main-body side. Eight cases were high-risk, requiring the presence of an experienced surgeon. Excluded cases had significantly shorter proximal LZ, larger aortic diameters 15mm below the renal artery and tortuous access routes on preliminary measurement by inexperienced doctor. Perioperative mortality was 0%, while the major complications were injury to the iliac artery in one high-risk case and thromboembolism of the superficial femoral artery in another. Perioperative proximal type I endoleak occurred in 5 cases. In 3 of these cases, the endoleak was eliminated by implantation of a Palmatz stent. In the other 2 cases, it disappeared within a month without additional procedures. These cases had a significantly greater angle between the proximal LZ and the suprarenal aorta and significant amount of mural thromboses in the proximal LZ. Perioperative type III endoleak occurred in 3 cases. In all cases the endoleak was eliminated by additional procedure. Perioperative type II endoleak occurred 8 cases. In 3 of these cases, the endoleak disappeared within a month. In the 5 other cases, the endoleak did not disappear. Mid-term results showed iliac leg thromboembolism in one case and new type II endoleaks in 3 caces. Type II endoleak occurred in cases which had significantly greater angles between the proximal LZ and the aneurysm. The results which were evaluated in our center had excellent perioperative and mid-term outcomes. We think this evaluation system is effective for risk assessment and reduces the learning curve in EVAR. In anatomically marginal cases, it is possible for proximal type I endoleak and injury of the iliac artery to occur. It is impossible to exclude these marginal cases if treatment need for EVAR is a priority. In these cases, lessexperienced operators should be trained in troubleshooting techniques in advance.
　Jpn. J. Cardiovasc. Surg. 37: 311-316 (2008)

Initial Experience with the MC³ Annuloplasty Ring for Tricuspid Regurgitation 　　J. Kawamoto et al.……317

Initial Experience with the MC³ Annuloplasty Ring for Tricuspid Regurgitation: Comparison to the Cosgrove-Edwards Ring Jun

(Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Center, Kure, Japan)

Jun Kawamoto Hironori Izutani Takanori Shibukawa

Shingo Mochiduki and Dairoku Nishikawa

The Edwards MC³ tricuspid annuloplasty system has recently become available commercially. Its anatomically correct design conforms to the three-dimensional tricuspid orifice and minimizes stress on sutures. We handled 71 patients with functional tricuspid regurgitation by open heart surgery and tricuspid valve repair between May 2005 and April 2007 in our institute. Cosgrove-Edwards annuloplasty rings were used for tricuspid regurgitation in 33 patients before October 2006. Among them, there were 30 mitral valve surgeries, 6 aortic valve surgeries, and 2 cases of atrial septal defect. Since then, we used the MC³ system in 38 cases, consisting of 30 mitral valve surgeries, 9 aortic valve surgeries, and 2 cases of atrial septal defect. Three patients died postoperatively with the Cosgrove-Edwards system, but there was no fatality with the MC³ system. The degree of tricuspid regurgitation was reduced from 2.6±0.58 to 0.34±0.46 (regurgitation severity scale: 0 to 4) in the patients with the MC³ ring at discharge. In the 33 patients with the Cosgrove-Edwards ring, it was from 2.8±0.67 to 0.92±0.99. The severity of tricuspid regurgitation in patients with the Cosgrove-Edwards ring and the MC³ ring about nine months postoperative was 1.5±1.2 and 0.42±0.50, respectively. The MC³ (rigid ring) system was more effective than the Cosgrove-Edwards (flexible band) system for decreasing tricuspid regurgitation in immediate and short-term postoperative periods.
　Jpn. J. Cardiovasc. Surg. 37: 317-320 (2008)

Case Reports

Primary Cardiac Lymphoma in the Right Atrium 　　M. Motoki et al.……321

Primary Cardiac Lymphoma in the Right Atrium

(Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan)

Manabu Motoki Toshihiro Fukui Yasuyuki Sasaki

Toshihiko Shibata Hidekazu Hirai

Yosuke Takahashi and Shigefumi Suehiro

We report a rare case of primary cardiac lymphoma in the right atrium. An 85-year-old woman with severe heart failure was referred to our hospital. The echocardiography revealed a huge tumor occupying the right atrial cavity. We conducted an emergency operation to resect the tumor. However, as the tumor strongly adhered to the wall of the right atrium and tricuspid valve, we performed partial resection of the tumor to improve hemodynamics. The pathological examination of the tumor was consistent with malignant lymphoma of B-cell origin. Although the postoperative chemotherapy was effective to reduce a volume of the tumor, the patient died because of the adverse reaction to medication.
　Jpn. J. Cardiovasc. Surg. 37: 321-324 (2008)

Surgical Coronary Revascularization in a Patient Resuscitated from Out-Of-Hospital Cardiac Arrest 　　H. Sakaguchi and S. Azuma……325

Surgical Coronary Revascularization in a Patient Resuscitated from Out-Of-Hospital Cardiac Arrest

(Department of Cardiovascular Surgery, Chiba Tokushukai Hospital, Hunabashi, Japan and Department of Cardiovascular Surgery, Kishiwada Tokushukai Hospital*, Kishiwada, Japan)

Hidehito Sakaguchi and Syuhei Azuma*

We report a 77-year-old man treated successfully surgical coronary revascularization following out-of-hospital cardiac arrest. The patient suddenly suffered from loss of consciousness with cardiopulmonary arrest on June 3, 2007. His wife quickly started cardiac massage and a bystander called an ambulance. Using an automated external defibrillator, paramedics performed defibrillation, which started his heart beating again in 30 min. He was then transferred by ambulance to the emergency room in our hospital. Severe coronary artery disease (left main disease and three-vessel disease) was diagnosed on June 11 after treatment for congestive heart failure and confirmation of good consciousness. Thereafter, urgent on-pump beating coronary artery bypass grafting was performed. On the 45th post operative day, the patient was discharged to home with an acceptable level of daily life activity. To the best of our knowledge, this is the fifth such case report in the Japanese literature.
　Jpn. J. Cardiovasc. Surg. 37: 325-328 (2008)

Aortic Valve Replacement after Retrosternal Gastric Tube Reconstruction for Esophageal Cancer 　　T. Iida et al.……329

Aortic Valve Replacement after Retrosternal Gastric Tube Reconstruction for Esophageal Cancer

(Department of SurgeryⅡ, Kochi University, Nankoku, Japan)

Takeshi Iida Hideaki Nishimori Takashi Fukutomi

Seiichiro Wariishi Masaki Yamamoto and Shiro Sasaguri

We present a case of aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer. A 84-year-old man with a history of esophageal resection with retrosternal reconstruction by gastric tube for esophageal cancer required aortic valve replacement for aortic stenosis. The aortic valve was approached through an 8-cm right parasternal incision over the third and fourth costal cartilages. Cardiopulmonary bypass was initiated through cannulas in the ascending aorta and the right atrium and the aortic valve was replaced with a bioprosthetic valve. The postoperative course was uneventful. In the literature, there are only 7 reports on such cases so far, in which aortic valve relplacement was performed through left thoracotomy, right parasternal approach or median sternotomy. We recommend the right parasternal approach in cases of aortic valve replacement in patients with retrosternal gastric tube, because it does not only avoids injury of gastric tube, but also offers an excellent operative view.
　Jpn. J. Cardiovasc. Surg. 37: 329-332 (2008)

A Case of Infected Thoracoabdominal Aortic Aneurysm Caused by Citrobacter koseri 　　A. Bito et al.……333

A Case of Infected Thoracoabdominal Aortic Aneurysm Caused by Citrobacter koseri

(Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan)

Atsushi Bito Yutaka Narahara

Noboru Murata and Noboru Yamamoto

The patient was a 58-year-old woman with untreated diabetes. She consulted a local doctor in May 2006 complaining of constipation that had persisted for 2 weeks, under gradually worsening abdominal pain. She was transferred to our hospital with a diagnosis of aortic aneurysm. Blood tests indicated high inflammatory response, and CT showed hematoma around the aorta from directly under the diaphragm to the level of superior mesenteric artery and influx of contrast medium into the hematoma. Control of the infection was first attempted with antibiotics, but eventually surgery was performed because the hematoma increased. The hematoma and aortic wall were completely excised from the local of the diaphragm to the level beneath the renal artery, with partial cardiopulmonary bypass and selective perfusion to abdominal branches, and anatomic reconstruction was performed with a synthetic graft and omental implantation. The hematoma was fetid and Citrobacter koseri was detected in culture. The patient was discharged after 4 weeks of antibiotic treatment, without complications and with satisfactory progress. At present, there has been no recurrence of infection in the 22 months since her discharge.
　Jpn. J. Cardiovasc. Surg. 37: 333-336 (2008)

Surgical Correction for Congenital Valvular and Supravalvular Aortic Stenosis Associated with Coronary Ostial Stenosis in a Child 　　M. Sato et al.……337

Surgical Correction for Congenital Valvular and Supravalvular Aortic Stenosis Associated with Coronary Ostial Stenosis in a Child

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

Masataka Sato Yuji Hiramatsu Hideyuki Kato

Muneaki Matsubara Chiho Tokunaga Shinya Kanemoto

Mio Noma Masakazu Abe* and Yuzuru Sakakibara

Supravalvular aortic stenosis is a rare obstructive lesion of the left ventricular outflow tract localized at the level of sinotubular junction. It has been recognized that supravalvular stenosis may occur as a part of Williams syndrome and is sometimes complicated by obstruction of the left main coronary artery. We successfully performed single patch augmentation for supravalvular aortic stenosis and left coronary ostial stenosis with concomitant aortic valvotomy in a child without Williams syndrome. The patient had been followed as congenital bicuspid aortic valvular and supravalvular stenosis. At the age of 3 years, cardiac catheterization revealed an increased pressure gradient of 90mmHg at the left ventricular outflow and newly developed ostial stenosis of the left coronary artery. An oblique incision on the ascending aorta was made above the sinotubular junction and extended leftward onto the left main coronary artery, and this incision opened the fibrous ridge at the left coronary artery. After commissurotomy for the bicuspid valve, both the supravalvular and ostial stenosis were augmented with a single autologous pericardial patch treated by glutaraldehyde. The pressure gradient was significantly reduced and the ischemic left ventricular dysfunction was eliminated.
　Jpn. J. Cardiovasc. Surg. 37: 337-340 (2008)

Late Cardiac Perforation after Atrial Septal Defect Closure with the Amplatzer Septal Occluder 　　N. Enomoto et al.……341

Late Cardiac Perforation after Atrial Septal Defect Closure with the Amplatzer Septal Occluder

(Department of Cardiovascular Surgery, St. Mary’s Hospital, Kurume, Japan)

Naofumi Enomoto Hiroshi Yasunaga Hideki Sakashita

Muneaki Matsubara Takahiro Shojima and Kageshige Todo

Percutaneous transcatheter closure of ostium secundum atrial septal defect (ASD) has become an alternative to conventional open surgical repair. Cardiac perforation is a rare complication after transcatheter closure of ASD by an Amplatzer Septal Occluder (ASO). We present a patient with hemodynamic collapse secondary to cardiac perforation occurring 5 months after placement of the ASO and discuss the complications of this device. A 14-year-old girl underwent transcatheter closure of ASD by the ASO in our institution. Transesophageal echocardiography showed ASD sized 17.4×15.0mm, with no aortic rim. The placement of the ASO was performed without complications, but 5 months after the procedure she started to complain of chest pain and subsequent syncope. She was brought to a local emergency department. Transthoracic echocardiography showed an important cardiac effusion with signs of cardiac tamponade. Emergency pericardial drainage was performed under echocardiographic control from the subxiphoidal region. Once she was hemodynamically stabilized, the patient was transferred to our institution immediately for the necessary emergency surgical procedure. The operation was performed through a median sternotomy and the bleeding source was identified. The left-side of the ASO disc had cut through the roof of the left atrium between the superior vena cava and the aortic root, creating a 5-mm perforation. There was another perforation at the aortic root in the region of the non-coronary sinus of Valsalva, approximately 5 mm. The metallic rim of the ASO could be easily seen protruding through the roof of the left atrium. Cardiopulmonary bypass was established and cardiac arrest induced. After opening the right atrium we found the ASO, which was positioned well. The ASO was removed and the perforations of the aortic root and the left atrium were closed with 5-0 polypropylene directly. Then the ASD was closed using an autopericardial patch. The patient was weaned off bypass without difficulty. The postoperative course of the patient was uneventful and free of neurologic events. Finally, we conclude that patients with an aortic rim defect may be at higher risk for device perforation. Such a patient should be carefully followed up by echocardiography.
　Jpn. J. Cardiovasc. Surg. 37: 341-344 (2008)

Endovascular Repair of Chronic Aortic Dissection Expansion from Distal Fenestration in Previous Graft Replacement 　　T. Ito et al.……345

Endovascular Repair of Chronic Aortic Dissection Expansion from Distal Fenestration in Previous Graft Replacement

(Department of Thoracic and Cardiovascular Surgery and Department of Traumatology and Critical Care Medicine*, Sapporo Medical University, Sapporo, Japan)

Toshiro Ito Yoshihiko Kurimoto* Nobuyoshi Kawaharada

Tomohiro Nakajima Masaki Tabuchi Mayuko Uehara

Yousuke Yanase Akihiko Yamauchi

Toshio Baba and Tetsuya Higami

A 58-year-old man was admitted because of enlargement in diameter of the descending thoracic aorta. Six years previously, he had undergone graft replacement of the proximal descending aorta due to a chronic dissecting aneurysm. During that surgery, distal fenestration involving resection of the intimal flap of the distal anastomotic site and graft replacement with distal anastomosis of the true and false lumen were performed. Our preoperative enhanced computed tomography (eCT) revealed a thoracic aortic aneurysm 58mm in diameter at the site of distal fenestration. Graft replacement through left lateral thoracotomy was considered difficult because of previous occurrence of methicillin-resistant Staphylococcus aureus (MRSA) empyema after the previous operation: hence, endovascular repair was done using a handmade stent graft to interrupt blood flow into the false lumen. The postoperative course was uneventful. Postoperative eCT showed the thrombosed false lumen and the shrinkage of the aneurysm from 58 to 38mm in diameter over a period of 18 months.
　Jpn. J. Cardiovasc. Surg. 37: 345-348 (2008)

A Successful Treatment for Myonephropathic Metabolic Syndrome and Delayed Intestinal Ischemia after Operation of Acute Type B Aortic Dissection with Bilateral Lower Limb Ischemia 　　H. Kurosawa et al.……349

A Successful Treatment for Myonephropathic Metabolic Syndrome and Delayed Intestinal Ischemia after Operation of Acute Type B Aortic Dissection with Bilateral Lower Limb Ischemia

(Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan)

Hiroyuki Kurosawa Hirono Satokawa Yoichi Sato

Shinya Takase Yukitoki Misawa Hiroki Wakamatsu

Yuki Seto Eitoshi Tsuboi

Kenichi Muramatsu and Hitoshi Yokoyama

A 20-year-old man suddenly complained of back pain and bilateral lower limb weakness. Computed tomography showed acute type B aortic dissection. The patent false lumen extended from distal arch to the left common iliac artery. The true lumen was severely compressed by the false lumen and both legs were ischemic. He underwent emergency fenestration of the abdominal aorta and stenting of the left iliac artery. Although the lower limbs ischemia was improved, he developed myonephropathic metabolic syndrome and received plasma exchange, continuous hemodialysis and endotoxin absorption therapy. Thirteen days after the operation, intestinal ischemia occurred and he underwent emergency bowel resection with creation of a stoma. Development of dissection to the superior mesenteric artery (SMA) and the malperfusion of SMA by severe compression of the true lumen were thought to cause intestinal ischemia.
　Jpn. J. Cardiovasc. Surg. 37: 349-352 (2008)

Acute Type A Aortic Dissection with Acute Left Main Coronary Trunk Occlusion 　　M. Hatakeyama et al.……353

Acute Type A Aortic Dissection with Acute Left Main Coronary Trunk Occlusion: A Case Report of Left Main Stenting as a Bridge to Surgery

(Department of Thoracic and Cardiovascular Surgery, Funabashi Municipal Medical Center, Chiba, Japan)

Masaharu Hatakeyama Yoshiharu Takahara

Kenji Mogi and Masashi Kabasawa

A 56-year-old man was admitted to our institution with sudden onset of severe chest pain and ischemia of the lower extremities on February 24, 2007. An enhanced computed tomography scan showed acute Stanford type A aortic dissection. Electrocardiography showed ST segment elevation in leads V_1-4 and a transthoracic echocardiogram revealed antero-septal wall akinesis. The patient was given a diagnosis of acute myocardial infarction (AMI) caused by left main trunk dissection (LMT) due to acute aortic dissection. Coronary angiography (CAG) showed severe stenosis in the LMT with poor distal run-off. For this reason, after we implanted a stent in the left main coronary trunk to maintain coronary blood flow, we performed total aortic arch replacement, coronary artery bypass grafting (SVG-LAD＃8), and F-F cross-over bypass. Removal of the implanted stent from the LMT during the operation was simple. Postoperative CAG showed a patent SVG and intact LMT. Because preoperative PCI is still controversial for acute aortic dissection with AMI, either more immediate surgery or preoperative PCI (bridge stent to surgery) in the left main coronary artery is mandatory. Implantation of an LMT stent, as a bridge to surgery, is an effective strategy for acute type A aortic dissection with LMT occlusion before surgical repair.
　Jpn. J. Cardiovasc. Surg. 37: 353-357 (2008)

Apicoaortic Conduit for Aortic Valve Stenosis after Coronary Bypass Grafting 　　M. Yamasaki et al.……358

Apicoaortic Conduit for Aortic Valve Stenosis after Coronary Bypass Grafting

(Department of Cardiovascular Surgery, Juntendo University School of Medicine, Tokyo, Japan and Department of Cardiovascular Surgery, Suwa Red Cross Hospital*, Suwa, Japan)

Motoshige Yamasaki Taira Yamamoto

Naohiko Sagawa Keita Kikuchi Keiichi Tambara

Atsushi Amano and Takahiro Takemura

The patient was a 74-year-old man with a history of previous aorto-coronary bypass grafting 14 years previously. Echocardiography showed severe aortic valve stenosis. Computed tomography showed severe circumferential aortic calcification of the whole aorta, including the aortic root. Coronary cineangiography showed patency of the endoric graft. Avoiding graft injury and aortic cross clamping, we performed apicoaortic conduit. His postoperative course was uneventful, he was discharged very much improved on the 11th postoperative day. This procedure is useful in high risk patients with aortic valve stenosis.
　Jpn. J. Cardiovasc. Surg. 37: 358-363 (2008)

A Large Pseudoaneurysm of the Aortic Arch due to Penetrating Atherosclerotic Ulcer 　　T. Yamagishi and K. Sakata……364

A Large Pseudoaneurysm of the Aortic Arch due to Penetrating Atherosclerotic Ulcer

(Department of Cardiovascular Surgery, National Hospital Organization Takasaki National Hospital, Takasaki, Japan)

Toshiharu Yamagishi and Kazuhiro Sakata

A 72-year-old man underwent hemiarch replacement of the distal aortic arch with hypothermia and selective cerebral perfusion because of a large pseudoaneurysm of the aortic arch. Histological examination revealed a penetrating atherosclerotic ulcer had caused aortic perforation and resultant pseudoaneurysm formation.
　Jpn. J. Cardiovasc. Surg. 37: 364-367 (2008)

Two Cases of Y-Grafting Using Terminal Branches of the Left Internal Thoracic Artery for Coronary Artery Bypass 　　H. Nakagawa et al.……368

Two Cases of Y-Grafting Using Terminal Branches of the Left Internal Thoracic Artery for Coronary Artery Bypass

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

Hirofumi Nakagawa Tatsuya Nakao and Norifumi Shigemoto

The excellent long term-patency rates achieved using the internal thoracic arteries (ITAs) have expanded the variety of graft arrangements of these conduits for multivessel coronary revascularization. We encountered 2 patients who underwent multivessel coronary artery bypass, by using these terminal branches of the left ITA effectively. In both patients, LITAs were taken down using the skeletonization technique with a harmonic scalpel. One patient had 2 grafts using the off-pump technique with the Y-composite grafts constructed by the main LITA trunk and LITA terminal branch, which were anastomosed with the left anterior descending branch (LAD) and diagonal branch (D1), respectively. The other patient had 6 grafts under on-pump cardiac arrest, including the natural LITA terminal branches which were anastomosed with the LAD and D1. Postoperative multidetector computed tomography (MDCT) revealed excellent long-term patent grafts in both patients. In conclusion, the terminal branches of the ITA, if of suitable size and length, could be used effectively to construct a Y-anastomosis for the coronary arteries, when consideration for the size of the target coronaries and native-coronary blood flow competition.
　Jpn. J. Cardiovasc. Surg. 37: 368-371 (2008)

A Case of Coronary Artery Spasm in the Perioperative Period of Off-Pump Coronary Artery Bypass Grafting after Drug-Eluting Stent Implantation 　　S. Tomari et al.……372

A Case of Coronary Artery Spasm in the Perioperative Period of Off-Pump Coronary Artery Bypass Grafting after Drug-Eluting Stent Implantation

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

Shiro Tomari Masaru Sawazaki Koji Yamana

Wataru Katou* and Yuichi Ueda*

In 2005, a 64 year-old man underwent implantation of a sirolimus-eluting stent at another hospital for the treatment of severe stenosis of the right coronary artery (RCA) that caused unstable angina pectoris affecting the inferior cardiac wall. He was subsequently admitted to our hospital because of recurrent angina. Diagnostic coronary angiography, performed in November 2006, revealed 75% stenosis of the left main trunk and 99% stenosis of the left circumflex artery. We planned to perform off-pump coronary artery bypass grafting on May 6, 2007. Ticlopidine and aspirin were discontinued 14 days and 1 day before the operation, respectively. We then started continuous intravenous heparin administration. During the operation, the right internal mammary artery was grafted to the left anterior descending artery, and after rotation of the heart in order to graft to the circumflex artery, hypotension and ST elevation in electrode Ⅱ occurred. The left internal mammary artery was grafted to the left circumflex artery under the support of intra-aortic balloon pumping, but the ST elevation did not normalize. Therefore, an extracorporeal cardiopulmonary bypass was started. Despite the coronary recanalization, the ST elevation in electrodeⅡdid not recover. Because of thrombosis of the drug-eluting stent, an aorto-coronary bypass graft to the RCA was performed with a saphenous vein graft. There was no proximal blood flow at the RCA incision. Therefore, we perfused the RCA via a shunt tube from the cardiopulmonary bypass, and subsequently the ST change normalized. However, ST elevation recurred after the operation. An emergency angiography performed immediately postoperatively revealed a patent saphenous vein graft and drug-eluting stent, and spastic change in the RCA distal from drug-eluting stent. After the initiation of a continuous intravenous drip of nicorandil, hypotension and the ST change recovered. Attention to coronary artery spasm after drug-eluting stent implantation is important.
Jpn. J. Cardiovasc.Surg. 37: 372-376 (2008)

Newly-Devised Technique of Senning Atrial Switch in Double Switch Operation 　　K. Agematsu et al.……377

Newly-Devised Technique of Senning Atrial Switch in Double Switch Operation

(Department of Cardiovascular Surgery, Chiba Children’s Hospital, Chiba, Japan and present address: Department of Cardiovascular Surgery, Tokyo Wemen’s Medical University*, Tokyo, Japan)

Kota Agematsu Mitsuru Aoki

Yuji Naito and Tadashi Fujiwara

We performed a double switch operation for the patients with corrected congenital transposition of the great arteries concomitant with intra-cardiac abnormalities including dextrocardia, non-confluent pulmonary artery and Ebstein’s malformation between April 2003 and August 2006. The mean age and weight at the time of surgery were 38 months (range 2-89 months) and 10.7kg (range 4.6-16.1kg), respectively. Before the double switch operation, one patient had received a right modified BT shunt as a neonate and another had received bilateral modified BT shunts at the age of one month and 2 months respectively, followed by a central pulmonary artery angioplasty with installation of a right ventricle to a pulmonary artery shunt at the age of 5 years. For definitive repair, the Senning＋Rastelli procedure was performed in two patients and Senning＋Jatene procedure was performed in one patient. Mitral valve-and tricuspid valve plasties were performed, the atrialized right ventricle was plicated in the patient with Ebstein’s malformation during the double switch operation. A Senning procedure was performed in patients with apicocaval juxtapositions. We reconstructed the systemic venous chamber with a dog-ear-like structure made from suture line pouches at the site of upper and lower portions of the atrial free wall, and the pulmonary venous chamber was completed, without augmentation with additional material. The mean surgery, cardiopulmonary bypass-and aortic cross clamp times were 606, 318 and 151 min, respectively. Postoperative CT scans showed smooth systemic venous returns and no pulmonary vein obstruction. No arrhythmias of any kind were detected after the double switch operation. These results suggest the suture line pouch technique in the atrial switch operation is useful in the double switch operation.
Jpn. J. Cardiovasc. Surg. 37: 377-380 (2008)

Long-Term Clinical Results of Inferior Vena Cava Right Atrium Bypass Surgery Using Ring-Reenforced Expanded Polytetrafluoroethylene (EPTFE) Graft to Budd-Chiari Syndrome 　　M. Toyama et al.……381

Long-Term Clinical Results of Inferior Vena Cava Right Atrium Bypass Surgery Using Ring-Reenforced Expanded Polytetrafluoroethylene (EPTFE) Graft for Budd-Chiari Syndrome

(Division of Surgery, Cardiovascular Center, Okinawa Kyodo Hospital, Tomigusuku, Japan and Kaisei Clinic*, Naha, Japan)

Masato Toyama Mitsunori Okiyama

Hiromu Terai and Kiyomitsu Kinjo*

Since January 1981, we have performed bypass surgery between the inferior vena cava and the right atrium (IVC-RA bypass) using ring-reenforced expanded polytetrafluoroethylene (EPTFE) graft in five cases of Budd-Chiari syndrome in which at least one or more hepatic veins or accessory hepatic veins connected with the inferior vena cava. IVC-RA bypass cases include two men and three women aged 33 to 61 years old. The EPTFE graft was cut just outside of the ring and anastomosed to the inferior vena cava and the right atrium. The ring was utilized to keep the anastomosed orifice circular. EPTFE grafts (14 to 16mm in diameter and 24 to 27cm in length) were placed through the route alongside the second portion of the duodenum behind the transverse colon and anterior to the liver. Warfarin was given as an anticoagulant for at least several months to several years postoperatively in 4 cases with life-long time in one case. The cases have been followed up for 4 to 24 years. Three patients showed good graft patency for 20 years or more after the operation. Two cases died of rupture of esophageal varices 12 and 23 years after the bypass surgery, respectively. IVC-RA bypass using ring-reenforced EPTFE graft for Budd-Chiari syndrome is expected to have good long term patency without long term anticoagulant therapy, but its effect on preventing the progress of liver cirrhosis and esophageal varices is limited. Therefore IVC-RA bypass is a choice, when direct reconstruction of the hepatic vein and the inferior vena cava is impossible.
Jpn. J. Cardiovasc. Surg. 37: 381-384 (2008)