Japanese Journal of Cardiovascular Surgery Vol.38, No.3

Originals

  • Change of Oxidative Stress in Cases of Cardiac and Aortic Surgeries E. Inagaki et al.……169
    Change of Oxidative Stress in Cases of Cardiac and Aortic Surgeries

    （Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kawasaki Medical School Hospital, Kurashiki, Japan）

    Eiichiro Inagaki Sohei Hamanaka Hitoshi Minami
    Hisao Masaki Atsushi Tabuchi Yasuhiko Yunoki
    Hiroshi Kubo Takuro Yukawa Kazuo Tanemoto
    We measured oxidative stress and antioxidative stress in clinical cases of cardiac and aortic surgery, especially in extracorporeal circulation cases. From June to October 2007, 18 cases who underwent cardiac and aortic surgery with extracorporeal circulation（ECC group）and 8 cases with an infra-renal abdominal aortic aneurysm（AAA group）were studied. We measured reactive oxygen metabolites（d-ROM）in oxidative stress for the operative time, after the operation endpoint, and at one day postoperatively, one, two, and three weeks postoperatively, and one, two, three, and four months postoperatively. Regarding d-ROM, the level in the ECC group was significantly higher than that in the AAA group（p＜0.0001). Peak values were observed 3 weeks postoperatively in the ECC group and 2 weeks postoperatively in the AAA group. Although the oxidative stress increased in both groups, the peak value in the ECC group was more marked than that in the AAA group. We concluded that oxidative stress under surgical stress in cardiovascular surgery with extracorporeal circulation was higher than that under surgical stress in cardiovascular surgery for infra-renal abdominal aortic aneurysms.
      Jpn. J. Cardiovasc. Surg. 38:169-174（2009）
  • Efficacy of Short-Acting β-Blockers after Cardiac Surgery H. Suzuki et al.……175
    Efficacy of Short-Acting β-Blockers after Cardiac Surgery

    （Department of Surgery, Cardiovascular Division, Teikyo University School of Medicine）

    Haruo Suzuki Susumu Ishikawa Susumu Kadowaki
    Keisuke Nakamura Keiko Abe Akio Kawasaki
    Kazuo Neya Keisuke Ueda
    The efficacy of Landiolol hydrochloride（Onoact®）for the treatment of arrhythmia was studied in 10 adult patients who underwent cardiovascular surgery. Onoact was continuously infused at a mean rate of 0.018mg/kg/min initially and followed by 0.01mg/kg/min. After the initiation of Onoact infusion, supra-ventricular tachycardia was eliminated in 5 out of 6 patients, and ventricular tachycardia disappeared in all 4 patients. The decrease in systemic blood pressure was not significant. Low-dose continuous infusion of Onoact was safe and effective even in patients just after cardiovascular surgery.
      Jpn. J. Cardiovasc. Surg. 38:175-178（2009）
  • Effect of Ultra-Short-Acting β-Blocker Landiolol after Cardiovascular Surgery T. Sugiura et al.……179
    Effect of Ultra-Short-Acting β-Blocker Landiolol after Cardiovascular Surgery

    （Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan）

    Tadahisa Sugiura Masaaki Koide Yoshifumi Kunii
    Nobuhiro Umehara Kazumasa Watanabe
    Tachycardia caused by increased sympathetic nerve activity after cardiovascular surgery can induce an increase in myocardial oxygen consumption and myocardial ischemia. β-Blockers are expected to reduce myocardial oxygen consumption, but traditional β-blockers are long acting so it is difficult to use after cardiovascular surgery. >>From January 2007 to September 2007, 24 out of 60 patients who underwent cardiovascular surgery were administered landiolol. The average heart rate before landiolol infusion was 99.5±16.5bpm and decreased to 89.5±10.7bpm after landiolol infusion（p＝0.0008). Average systolic blood pressure before and after landiolol infusion was 109±16mmHg and 103±13mmHg, respectively（p＝0.15). Average cardiac index（14 patients）before and after landiolol infusion was 3.29±0.83l/min/m2and 3.26±0.9l/min/m2, respectively（p＝0.75). Four patients（17%）had atrial fibrillation during these hospital stay, whereas 20 patients out of 50 patients（40%）who underwent cardiovascular surgery before landiolol was used（from June 2006 to January 2007）had atrial fibrillation（p＝0.045). Landiolol can be effective and used safely after cardiovascular surgery.
      Jpn. J. Cardiovasc. Surg. 38:179-183（2009）
  • Process and Structure of Adult Cardiovascular Surgery Care in Japan H. Miyata et al.……184
    Process and Structure of Adult Cardiovascular Surgery Care in Japan

    （Graduate School of Medicine* and Faculty of Medicine**, The University of Tokyo, Tokyo, Japan, and Koshigaya Hospital, Dokkyo Medical University***, Koshigaya, Japan）

    Hiroaki Miyata* Noboru Motomura*,** Hiroyuki Tsukihara*
    Yoshihito Irie*** Shinichi Takamoto** JACVSD Organization
    In Japan, few surveys have evaluated the structure and clinical process of cardiovascular surgery programs. We mailed a questionnaire to all 149 facilities participating in the Japan Adult Cardiovascular Database as of April 1st 2007. We received responses from 129 facilities（response rate 86.6%). For CABG surgery, many facilities regard “IMA use（95.3%）” and “off-pump surgery” is the first choice as a facility and recommend “discharge antiplatelets（89.9%）” and “discharge antilipid（47.3%）”. On the other hand most facilities did not made any recommendation regarding “preoperative beta blockers（72.9%）” and “discharge beta blockers（60.5%）”. The usage rates of preoperative beta blockers and discharge beta blockers were very low in Japan though their usage rates were relatively high in the United States.
      Jpn. J. Cardiovasc. Surg. 38:184-192（2009）

Case Reports

  • Surgical Treatment for Double Valve Stenosis Using the Coupling Valve Method S. Tanabe et al.……193
    Surgical Treatment for Double Valve Stenosis Using the Coupling Valve Method

    （Department of Surgery, Kochi Health Sciences Center, Kochi, Japan）

    Sawaka Tanabe Kensuke Oue Shinji Kanemitsu
    Hiroyuki Miyagawa Youichirou Miyake Manabu Okabe
    A 44-year-old woman with dyspnea on effort was admitted. Aortic stenosis and mitral stenosis and pulmonary hypertension were diagnosed. She underwent surgical treatment for her aortic valve and mitral valve by enlarging the aortic and mitral valve ring and replacing them by modified coupling valve methods. The postoperative course was uneventful and she was discharged on the 21st postoperative day.
      Jpn. J. Cardiovasc. Surg. 38:193-196（2009）
  • OPCAB after Placement of Drug-Eluting Stent:A Case of Cardiac Tamponade Developing after Resumption of Ticlopidine Administration in the Early Postoperative Period K. Izumi et al.……197
    OPCAB after Placement of Drug-Eluting Stent:A Case of Cardiac Tamponade Developing after Resumption of Ticlopidine Administration in the Early Postoperative Period

    (Division of Cardiovascular Surgery, Sasebo City General Hospital, Nagasaki, Japan)

    Kenta Izumi Yoichi Hisata Shiro Hazama
    A 72-year-old man presented with a chief complaint of chest pain. Since ECG showed ST elevation in leads III and aVF, suggestive of acute myocardial infarction, we performed emergency coronary angiography which revealed total occlusion of RCA#3, 75% stenosis of LAD#6, and 99% stenosis of LAD#7. Thus, RCA occlusion was the likely cause of the chest pain, and a drug-eluting stent (DES) was placed in RCA#3. OPCAB of the LITA to the LAD (LITA-LAD) was performed 44days later. The volume of postoperative drainage was very low, and, since the DES was in place, the administration of aspirin 100mg once daily and ticlopidine 200mg twice daily was started on the first morning after surgery. On the second morning after surgery, the CVP rose rapidly to 16, and then to 23mmHg. Chest CT revealed massive hemopericardium and hemomediastinum, and re-thoracotomy was performed for hematoma removal. There was no bleeding at the anastomosis or graft sites, with minimal bleeding from mediastinal adipose tissue. Thereafter, his condition improved uneventfully, and he was discharged on the 19th postoperative day. Since the DES was in place, the administration of antiplatelet agents was resumed in the early postoperative period to prevent occlusion, which resulted in the development of cardiac tamponade due to bleeding. We report the case of severe postoperative complication due to DES placement.
      Jpn. J. Cardiovasc. Surg. 38:197-200（2009）
  • Re-Mitral Valve Replacement（MVR）for Severe Mitral Regurgitation due to Retraction of a Mosaic Porcine Bioprosthesis Valve’s Leaflet in the First Year of MVR M. Fukuoka and T. Takeuchi……201
    Re-Mitral Valve Replacement (MVR) for Severe Mitral Regurgitation due to Retraction of a Mosaic Porcine Bioprosthesis Valve’s Leaflet in the First Year of MVR

    (Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan)

    Masahira Fukuoka Toshifumi Takeuchi
    A 70-year-old man received a mitral valve replacement (MVR) using a Mosaic valve for mitral regurgitation with valve tethering due to ischemic cardiomyopathy a year previously. Echocardiogram demonstrated mitral prosthetic valve regurgitation due to fixed leaflet 6 months ago. Despite medical treatment, he complained of dyspnea and renal function worsened. Therefore, he underwent re-MVR in the first year of MVR. We replaced the mitral valve with mechanical valve via right thoracotomy. Severe pannus growth was found in a non-coronary cusp corresponding to the posterior leaflet of the mitral valve. The bioprosthetic valve leaflet was folded and compacted by the pannus that covered the outflow surface of the leaflet.
      Jpn. J. Cardiovasc. Surg. 38:201-204（2009）
  • Cell-Free and Concentrated Pleural Effusion Reinfusion Therapy for Postoperative Chylothorax Y. Sawada et al.……205
    Cell-Free and Concentrated Pleural Effusion Reinfusion Therapy for Postoperative Chylothorax

    (Department of Cardiovascular Surgery, Ijinkai Takeda General Hospital, Kyoto, Japan, and Cardiovascular Center, Kyoto Katsura Hospital*, Kyoto, Japan)

    Yoshihide Sawada Yukiya Nomura Yasuyoshi Yoshii*
    Chylothorax is a rare but serious complication of thoracic surgery, with a poor prognosis, unless treated properly. We report the case of a 73-year-old man who developed massive chylothorax after thoracic aortic replacement. The patient was initially treated conservatively and during this period, we applied CART (Cell-free and Concentrated Ascites Reinfusion Therapy) method which performed thoracic drainage fluid to keep the patient’s condition well. Administration of octreotide was not effective in this case. Thoracic duct ligation was eventually performed after the thoracic duct laceration was confirmed by lymphangiography. The patient recovered well and was discharged with no sign of recurrence.
      Jpn. J. Cardiovasc. Surg. 38:205-207（2009）
  • A Case of Left Ventricle Aneurysm（LVA）with Ventricular Septal Perforation（VSP）after Inferior Myocardial Infarction D. Tasaki et al.……208
    A Case of Left Ventricle Aneurysm (LVA) with Ventricular Septal Perforation (VSP) after Inferior Myocardial Infarction

    (Department of Thoracic Surgery, Ome Municipal General Hospital, Tokyo, Japan)

    Dai Tasaki Nagahisa Oshima Toshizumi Shirai
    Satoru Makita
    A 68-year-old woman with a chief complaint of dyspnea was admitted in March, 2007. She had undergone percutaneous angioplasty of the right coronary artery in 2002. Elective surgery was advised because echocardiography, left ventricular cineangiography and 64-multidetector-row CT (64MDCT) had revealed a left ventricular aneurysm (LVA), a ventricular septal perforation (VSP) through the aneurysm, and three diseased coronary arteries. The aneurysm wall was located on the inferior wall, and this was incised longitudinally. The VSP was directly sutured using 4-0 polypropylene, and the aneurysm was closed with large patches, and pledgetted mattress and running sutures. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. It is rare for LVA and VSP to be diagnosed simultaneously, but the risk of pseudo-false aneurysm of the left ventricle is high because of free wall rupture and septal wall perforation, and therefore surgical repair is recommended.
      Jpn. J. Cardiovasc. Surg. 38:208-211（2009）
  • Surgical Removal of Left Ventricular Thrombi Combined with Acute Myocarditis N. Tokunaga et al.……212
    Surgical Removal of Left Ventricular Thrombi Combined with Acute Myocarditis

    (Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan and Present address:Department of Cardiovascular Surgery, Okayama University Hospital*, Okayama, Japan and Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital**, Fukuyama, Japan)

    Noriyuki Tokunaga* Hideo Yoshida Kunikazu Hisamochi
    Keiji Yunoki Daisuke Futagami** Hironori Ebishima*
    Toshihiko Suzuki Hideyuki Kato Osamu Oba
    A 47-year-old man had suffered from high grade fever and dyspnea for 10 days. He was transferred to our hospital in a condition of shock. Echocardiography showed severe diffuse hypokinesis of left ventricle (EF 21%), and multiple mobile thrombi in the left ventricle. Under a diagnosis of LV thrombi due to acute myocarditis, transatrial removal of LV thrombi was performed using video-assisted cardioscopy. He was weaned from cardiopulmonary bypass under IABP support. Postoperatively, he suffered from thromboembolism of the cerebral and right brachial artery. Thrombectomy of the right brachial artery and anticoagulation therapy was performed. IABP was removed on POD 3, and he no longer needed respiratory control on POD 4. Echocardiography on POD 6 showed marked improvement of the LV contraction（EF 52%). After rehabilitation, he was discharged on POD 23 on foot. Video-assisted cardioscopy allowed transatrial removal of LV thrombi, and preserved left ventricular function by avoiding ventriculotomy. Perioperative thromboembolism must be taken care of for a patient with multiple LV thrombi.
      Jpn. J. Cardiovasc. Surg. 38:212-215（2009）
  • A Surgical Case of Sinus of Valsalva Aneurysm Diagnosed by Cardiac Multidetecter-Row Computed Tomography M. Takamatsu et al.……216
    A Surgical Case of Sinus of Valsalva Aneurysm Diagnosed by Cardiac Multidetecter-Row Computed Tomography

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

    Masanori Takamatsu Hitoshi Ohteki Kozo Naito
    Masayuki Sakaguchi Kouki Jinnouchi
    A 69-year-old man was admitted to our hospital due to cardiomegaly on plain chest radiography. He did not have any history of chest pain, trauma or fever of unknown origin. Echocardiography showed severe aortic valve regurgitation. Standard enhanced computed tomography（CT）showed a localized dissection or an aneurysm of the noncoronary sinus of Valsalva. However it is difficult to make a definite diagnosis because of cardiac beating artifact. Cardiac multidetecter-row CT demonstrated an aneurysm of the noncoronary sinus of Valsalva connected to the sinus with a small aperture. Aortic valve replacement and patch closure were performed. The postoperative course was uneventful and follow-up CT showed thrombus formation in the sinus Valsalva aneurysm. Cardiac multidetecter-row CT was useful for accurate diagnosis of aortic root disease.
      Jpn. J. Cardiovasc. Surg. 38:216-218（2009）
  • Reoperation in a Case of Thoracoabdominal Aortic Pseudoaneurysm after Patch Repair of Dissecting Aortic Aneurysm Y. Sekine et al.……219
    Reoperation in a Case of Thoracoabdominal Aortic Pseudoaneurysm after Patch Repair of Dissecting Aortic Aneurysm

    （Department of Cardiovascular Surgery, Tenri-yorozu Hospital, Nara, Japan）

    Yuji Sekine Daisuke Nakatsuka Michihito Nonaka
    Atushi Iwakura Kazuo Yamanaka
    A 63-year-old man had undergone patch repair of a chronic dissecting thoracoabdominal aortic aneurysm 8 years previously. Postoperative course was uneventful during 8 years after the first operation. However follow-up CT scan 8 years after demonstrated pseudoaneurysm of thoracoabdominal aorta at the anastomotic side. Reoperation for pseudoaneurysm was performed through left thoracotomy under partial cardiopulmonary bypass. Pseudoaneurysm was revealed at the proximal anastomotic side. Graft replacement for thoracoabdominal aorta and reconstruction of two pairs of intercostal arteries and the celiac artery was performed under SEP and MEP monitoring. His postoperative course was uneventful. He was discharged from our hospital 12 days after surgery. Follow-up CT scan demonstrates no recurrence of pseudoaneurysm for 1 year after surgery.
      Jpn. J. Cardiovasc. Surg. 38:219-222（2009）
  • Aortic Arch Replacement for Arch Aneurysm with a Porcelain Aorta Using Transapical Aortic Cannulation Y. Nishimura et al.……223
    Aortic Arch Replacement for Arch Aneurysm with a Porcelain Aorta Using Transapical Aortic Cannulation

    （Department of Cardiovascular Surgery, Kawasaki Saiwai Hospital, Kawasaki, Japan）

    Yoshiyuki Nishimura Shin Yamamoto Hideichi Wada
    Hiromine Fujita Yasuyuki Hosoda
    Porcelain aorta entails a high risk of cerebral as well as systemic embolism. We describe a case of aortic arch aneurysm with a circumferentially calcified aorta. The patient was a 61-year-old man on chronic hemodialysis who received aortic arch replacement. However, since chest CT scan revealed a totally calcified porcelain aorta and heavily calcified axillary artery, axillary artery cannulation was deemed to be contraindicated. On the other hand, possible complications caused by femoral artery cannulation are also well known, such as cerebral embolization. Therefore, transapical aortic cannula was used and aortic arch replacement was performed under deep hypothermic circulatory arrest. The patient was weaned from cardiopulmonary bypass without difficulty and had an uneventful recovery without any neurologic complications.
      Jpn. J. Cardiovasc. Surg. 38:223-225（2009）
  • A Case of Ascending-To-Descending Aorta Bypass Grafting for Coarctation of the Aorta Associated with Turner Syndrome R. Hirayama et al.……226
    A Case of Ascending-To-Descending Aorta Bypass Grafting for Coarctation of the Aorta Associated with Turner Syndrome

    （Department of Cardiovascular Surgery, Kumamoto Red Cross Hospital, Kumamoto, Japan, and Department of Cardiovascular Surgery, Kyoto First Red Cross Hospital*, Kyoto, Japan）

    Ryo Hirayama Masamichi Nakajima* Toshiya Koyanagi
    Ryusuke Suzuki Toshiaki Watanabe
    A 22-year-old woman without any serious distincted symptoms was found to have hypertension on a health examination. On further examinations, involving echocardiography and chest enhanced CT, showed dilatation of the ascending aorta, aortic coarctation, well-developed intercostal arteries and other collateral arteries. She was only 137cm tall and weighed 52kg. Besides, she had not had menstruation for the past two years. Chromosomal studies revealed Turner syndrome. Left lateral thoracotomy was thought to have the risk of heavy bleeding from collateral arteries, therefore we chose ascending-to-descending aorta bypass grafting through median sternotomy. She had an uncomplicated postoperative course. Here we report about operation in a adult case of coarctation of the aorta and discuss the usefulness of extraanatomical bypass grafting.
      Jpn. J. Cardiovasc. Surg. 38:226-228（2009）
  • Axillo-bilateral Iliac Artery Bypass for Atypical Coarctation of the Aorta with Severe Calcification T. Hachimaru et al.……229
    Axillo-bilateral Iliac Artery Bypass for Atypical Coarctation of the Aorta with Severe Calcification

    （Department of Cardiovascular Surgery, Tokyo Metropolitan Hiroo General Hospital, Tokyo, Japan）

    Tsuyoshi Hachimaru Satoru Kawaguchi Masazumi Watanabe
    Hideki Nakahara
    A 66-year-old woman had hypertensive heart failure and intermittent claudication due to coarctation of the aorta with severe calcification. Consequently, axillo-bilateral iliac artery bypass was performed. Postoperatively, the difference in blood pressure between the upper and lower limbs decreased, the heart failure improved, and the intermittent claudication disappeared. The postoperative course was uneventful and the patient was discharged without complication 15 days after surgery. There are many case reports of aorto-aortic bypass for this disease;however, axillo-bilateral iliac artery bypass is an effective and less-invasive procedure. On the other hand, from the perspectives of long-term graft patency and abdominal visceral perfusion, careful postoperative follow-up of upper and lower limb blood pressure and renal perfusion is necessary.
      Jpn. J. Cardiovasc. Surg. 38:229-231（2009）
  • Isolated Injury of the Intrapericardial Pulmonary Vein Following a Blunt Trauma H. Tanaka and T. Kimura……232
    Isolated Injury of the Intrapericardial Pulmonary Vein Following a Blunt Trauma

    （Department of Cardiovascular Surgery, Shinbeppu Hospital, Oita, Japan）

    Hideyuki Tanaka Tatsunori Kimura
    A 25-year-old man crashed his car into an electric light pole, and was brought to our hospital. Pericardial effusion inducing cardiac tamponade was detected on computed tomography, but there was no findings suggesting traumatic injuries of any other organs. Since he demonstrated shock during the examination, we performed pericardial drainage following pericardiocentesis to eliminate the cardiac tamponade. After approximately 150ml of blood was drained, his blood pressure increased and stabilized. Blunt cardiac rupture was diagnosed after blood drainage, and midsternotomy was then performed. Percutaneous cardiopulmonary support was established for exploration and confirmation of the injured site. The injured site was confirmed at the junction of the right lower pulmonary vein and right basal pulmonary vein. However, surgical repair under partial circulatory support was impossible because the injury was complicated and hemorrhage was not controllable. Furthermore, there was a risk of air embolization during the process of repair. Therefore, an additional drainage tube was inserted into the superior vena cava, and then the injury was repaired by direct closure under total perfusion using another circulatory circuit with a venous reservoir. No cases of isolated injury of intrapericardial pulmonary vein injury have been reported previously. It was suspected that the development of this injury was related to air bag deployment. This case could be saved by surgical repair under total perfusion using cardiopulmonary bypass.
      Jpn. J. Cardiovasc. Surg. 38:232-234（2009）
  • Massive Endobronchial Hemorrhage after Cardiopulmonary Bypass Treated by Selective Bronchial Tamponade with a Bronchial Blocker Tube T. Ikuta et al.……235
    Massive Endobronchial Hemorrhage after Cardiopulmonary Bypass Treated by Selective Bronchial Tamponade with a Bronchial Blocker Tube

    （Department of Cardiovascular Surgery, Ishikiriseiki Hospital, Osaka, Japan）

    Takeshi Ikuta Motohiko Osako Masaya Kainuma
    Hiroshi Irie Hirofumi Fujii Yoshihiro Shimizu
    We report a case of massive endobronchial hemorrhage after cardiopulmonary bypass, and its successful treatment utilizing a bronchial blocker tube without circulatory support. An 85-year-old woman underwent mitral and tricuspid valves repair for mitral stenosis and regurgitation, and tricuspid regurgitation. The repairs were performed uneventfully. The patient was weaned from cardiopulmonary bypass. After protamine infusion, massive endobronchial hemorrhage occurred through the tracheal tube. On fiberoptic bronchoscopy, prompt identification and selective occlusion of the hemorrhage source was performed by a Coopdech endobronchial blocker tube（Daiken Medical Co., Ltd, Osaka, Japan). Postoperative contrast-enhanced computed tomography revealed thrombogenic pseudoaneurysm of the right middle lobe pulmonary artery. We speculated that Swan-Ganz catheters induced endobronchial hemorrhage. The patient did not experience any further hemorrhage. She was discharged from our hospital on the 25th postoperative day in good condition.
      Jpn. J. Cardiovasc. Surg. 38:235-238（2009）