Japanese Journal of Cardiovascular Surgery Vol.38, No.4

Case Reports

• Three Cases of Ascending Aorta-Abdominal Aorta Bypass for Atypical Coarctation with Takayasu’s Aortitis E. Inagaki et al.……239
  Three Cases of Ascending Aorta-Abdominal Aorta Bypass for Atypical Coarctation with Takayasu’s Aortitis

  （Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kawasaki Medical School, Kurashiki, Japan, Department of Surgery, Vascular Surger, Jikei University School of Medicine*, Tokyo, Japan, and Department of Cardiovascular Surgery, Tsuyama Central Hospital**, Tsuyama, Japan）

  Eiichiro Inagaki	Sohei Hamanaka	Hitoshi Minami
  Atsushi Tabuchi	Yasuhiro Yunoki	Hiroshi Kubo
  Yuji Kanaoka*	Mitsuaki Matsumoto**	Hisao Masaki
  Kazuo Tanemoto

  We report 3 cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu’s aortitis. We performed an extra-anatomical bypass from the ascending aorta to the terminal abdominal aorta. The graft was arranged to pass through the diaphragm from the pericardium, behind the left lobe of the liver and the stomach, to the front side of the pancreas to the terminal abdominal aorta. Although the graft was exposed in the abdominal cavity in part behind the stomach, it was completely covered with the great omentum thus avoiding direct contact between the graft the abdominal organs. Decrease in the pressure gradient between the ascending aorta and the abdominal aorta was achieved using a large prosthetic graft 14-16mm in diameter. There are several advantages with this technique.（1）Positional change during surgery can be avoided.（2）Anastomosis can be performed in non-diseased vessels.（3）This bypass graft can be branched off to visceral arteries if necessary. Reduction of the after load on the left ventricle and long-term graft patency by using a large diameter prosthetic graft were anticipated. The postoperative courses of all cases were satisfactory. Case 1 died of another disease 11 years and 11 months postoperatively, but the graft to was still patent.
    Jpn. J. Cardiovasc. Surg. 38:239-243（2009）
• A Traumatic Thoracic Aorta Injury Case Saved by Helicopter Transport and Emergency Surgery T. Ueda et al.……244
  A Traumatic Thoracic Aorta Injury Case Saved by Helicopter Transport and Emergency Surgery

  （Department of Thoracic and Cardiovascular Surgery, Toyama Prefectural Central Hospital, Toyama, Japan）

  Tetsuyuki Ueda	Masami Sotokawa	Minori Tateishi
  Saori Nagura	Shuichi Hoshino	Yasushi Nishiya

  This study reports a 38-year-old man who suffered traumatic thoracic aorta injury due to a fall accident during mountain climbing, and was saved by swift helicopter transport and emergency surgery. Approximately 2 h after the accident, the subject was brought to the hospital by the emergency helicopter transport service. Contrast-enhanced CT of the thorax and abdomen revealed leakage of the contrast medium from the aortic isthmus and a hematoma in the surrounding area. Thus, traumatic thoracic aorta injury was diagnosed and emergency surgery was performed. The patient went into a state of shock after being given anesthesia. Further rupture was diagnosed and a left fourth intercostal thoracotomy was performed immediately in order to control the hemorrhage. Concurrently, a partial cardio-pulmonary bypass was used. A lacerated foramen was observed across 1/3 of the lesser curvature of the aortic isthmus;the affected site was replaced by a prosthetic graft. The postoperative recovery was generally uneventful, and the patient was discharged from the hospital 30 days after the operation.
    Jpn. J. Cardiovasc. Surg. 38:244-247（2009）
• Vacuum-Assisted Closure for Mediastinitis Caused by Methicillin-Resistant Staphylococcus aureus after Coronary Artery Bypass Grafting A. Yuda et al.……248
  Vacuum-Assisted Closure for Mediastinitis Caused by Methicillin-Resistant Staphylococcus aureus after Coronary Artery Bypass Grafting

  （Department of Cardiovascular Surgery, Higashiyamato Hospital, Tokyo, Japan）

  Atsushi Yuda

  Sakashi Noji

  Takayuki Tatebayashi

  Mediastinitis caused by methicillin-resistant Staphylococcus aureus（MRSA）is a severe complication after coronary artery bypass grafting（CABG). Vacuum-Assisted Closure（VAC）therapy is a technical innovation in wound care. The advantage of VAC is the application of negative pressure to sternal wounds. A 73-year-old man was admitted to our hospital because of operation for triple vessel disease including left main coronary artery lesion. Off-pump CABG was performed using the bilateral internal thoracic arteries and right gastroepiploic artery. The postoperative course was uneventful. However, purulent discharge from a median sternostomy wound appeared on the 11th postoperative day. MRSA was identified by the culture of the wound exudate. On operation, the necrotic tissue was removed, and continuous irrigation and drainage were performed. Conventional technique was not effective. VAC therapy was applied on the 35th postoperative day. During VAC therapy, the wound became smaller and granulation tissue proliferated. VAC therapy was discontinued on the 208th postoperative day. Finally, the wound was naturally closed. He was discharged in good condition on the 213th postoperative day. VAC therapy was an effective treatment for MRSA mediastinitis after cardiac surgery.
    Jpn. J. Cardiovasc. Surg. 38:248-251（2009）
• Effect of Sildenafil on Pulmonary Hypertension after a Case of Residual Shunt of Ventricular Septal Defect M. Yamasaki et al.……252
  Effect of Sildenafil on Pulmonary Hypertension after a Case of Residual Shunt of Ventricular Septal Defect

  （Department of Cardiovascular Surgery, Juntendo University School of Medicine, Tokyo, Japan）

  Motoshige Yamasaki	Keiichi Tambara	Shiori Kawasaki
  Taira Yamamoto	Keita Kikuchi	Hirotaka Inaba
  Atsushi Amano

  A 60-year-old man, who underwent repair of ventricular septal defect（VSD）40 years previously, presented with dyspnea on effort and leg edema. Further examination showed residual VSD, mitral and tricuspid valve insufficiency, atrial flutter and pulmonary hypertension. We performed repair of the residual VSD, mitral valve replacement, tricuspid valve annuloplasty, and the Maze procedure. After surgery, systolic pulmonary arterial pressure decreased from 70 to 39mmHg. On the 4th postoperative day, his hemodynamic state was stable and he weaned from ventilator. He showed hypoxia with sticky excretions, and reintubation was done 10 h after extubation. After intubation, pulmonary hypertension continued, nitroglycerine administration was not effective but inhaleted nitric oxide（NO）improved pulmonary hypertension. On the 15th postoperative day, sildenafil administration from nasogastric tube was started the day before extubation. On postoperative echocardiogram on the 35th postoperative day, the systolic pulmonary arterial pressure was 30-40mmHg and left ventricular function was severely impaired because of the paradoxical movement of the ventricular septum after repair VSD. Sildenafil was safely used for the patient with heart failure and secondary pulmonary hypertension associated with congenital heart disease.
    Jpn. J. Cardiovasc. Surg. 38:252-258（2009）
• Endovascular Stent Graft Treatment for Celiac Aneurysm with Behçet Syndrome Y. Seto et al.……259
  Endovascular Stent Graft Treatment for Celiac Aneurysm with Behçet Syndrome

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

  Yuki Seto	Hirono Satokawa	Yoichi Sato
  Shinya Takase	Hitoshi Yokoyama

  A 38-year-old man underwent surgery for impending rupture of an inflammatory celiac artery aneurysm with a maximum diameter of about 50mm. First, an extra-anatomical bypass was performed from the iliac arteries to the celiac artery, superior mesenteric artery and bilateral renal artery using ringed ePTFE grafts. Second, the celiac artery aneurysm at the distal site was directly closed and then a stent graft was placed in the abdominal aorta to cover the orifice of the celiac artery. An endovascular stent graft treatment combined with extra-anatomical bypass is useful for the treatment of inflammatory aneurysm to avoid the various surgical complications in Behçet syndrome.
    Jpn. J. Cardiovasc. Surg. 38:259-261（2009）
• A Case of Septic Pulmonary Embolization due to Pacemaker Infection in Which Long-Term Perioperative Ventilation Was Required T. Yoshinaga et al.……262
  A Case of Septic Pulmonary Embolization due to Pacemaker Infection in Which Long-Term Perioperative Ventilation Was Required

  （Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan）

  Takashi Yoshinaga	Ryuji Kunitomo	Shuji Moriyama
  Kentaro Takaji	Yayoi Takamoto	Hidetaka Murata
  Michio Kawasuji

  Septic pulmonary embolization（SPE）is an uncommon pulmonary disorder. The diagnosis of SPE is frequently delayed because of its nonspecific chest roentgenological features. A 76-year-old woman who underwent pacemaker implantation one year previously received antibiotic therapy under a diagnosis of infectious colitis. She suffered septic shock and disseminated intravascular coagulation（DIC）and was admitted to our hospital. Methicillin-resistant Staphylococcus aureus（MRSA）was cultured from her blood and echocardiography demonstrated 13×16mm vegetation originating from the tricuspid valve. Multiple peripheral nodules with cavitation were found on chest computed tomography and she was given a diagnosis of SPE. She rapidly presented acute respiratory failure and mechanical ventilation was inevitable for 23 days before surgery. She underwent removal of the entire pacing system, resection and repair of the tricuspid valve and epicardial pacemaker lead implantation. Tracheostomy and long-term mechanical ventilation（16 days）was required after surgery, however, she was discharged from our hospital without any complication.
    Jpn. J. Cardiovasc. Surg. 38:262-265（2009）
• A Successful Case of Endovascular Treatment with Occlusion Stent Graft for Aortic Aneurysm Associated with Aortitis Syndrome Y. Seto et al.……266
  A Successful Case of Endovascular Treatment with Occlusion Stent Graft for Aortic Aneurysm Associated with Aortitis Syndrome

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

  Yuki Seto	Hirono Satokawa	Yoichi Sato
  Shinya Takase	Hitoshi Yokoyama

  A 46-year-old man was given a diagnosis of hypertension about 20 years previously. At age 41, aortitis syndrome was diagnosed, with descending thoracic aortic aneurysm and the coarctation of abdominal aorta by CT scan. He then underwent surgery to replace the descending thoracic aortic aneurysm and right axillo-bifemoral bypass. Recently, a thoraco-abdominal aortic aneurysm was pointed out at the distal site of the graft and, he was referred to our institute. We occluded the distal end of the aneurysm using an endoluminal occlusion stent graft. Today, in most cases of aortopathy associated with aortitis syndrome, surgical replacement of the aneurysms and extra-anatomical bypass is performed. An endovascular stent graft treatment combined with extra-anatomical bypass could be useful for various aortic disorders.
    Jpn. J. Cardiovasc. Surg. 38:266-269（2009）
• Successful Surgical Treatment of Isolated Iliac Aneurysm with Arterio-enteric Fistula S. Setozaki et al.……270
  Successful Surgical Treatment of Isolated Iliac Aneurysm with Arterio-enteric Fistula

  （Department of Cardiovascular Surgery, Matsue Red Cross Hospital, Matsue, Japan, Rakuyo Hospital*, Kyoto, Japan, Public Shiso General Hospital**, Shiso, Japan, and Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki Hospital***, Amagasaki, Japan）

  Shuji Setozaki	Mitsuhiko Matsuda*	Takeshi Soeda
  Sadatoshi Yuasa**	Kazuteru Shimizu***

  A 76-year-old male was admitted to our hospital because of melena. However, no remarkable findings of rupture were shown by enhanced CT scan and angiography. On the 9th day of admission, he fell into a state of shock because of sudden massive bloody intestinal discharge. Colonofiberscopic findings revealed a primary arterio-enteric fistula. Therefore, an emergency operation was undertaken. Following aneurysmectomy, colostomy was performed in the descending colon. Right axillo-femoral artery bypass was finally performed as an extra-anatomical bypass to secure the right leg blood flow.
    Jpn. J. Cardiovasc. Surg. 38:270-272（2009）
• A Successful Case of Selective Intercostal Arterial Perfusion in a Patient with Ruptured Thoraco-Abdominal Aortic Aneurysm T. Nakajima et al.……273
  A Successful Case of Selective Intercostal Arterial Perfusion in a Patient with Ruptured Thoraco-Abdominal Aortic Aneurysm

  （Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, Sapporo, Japan）

  Tomohiro Nakajima	Toshiro Ito	Nobuyoshi Kawaharada
  Mayuko Uehara	Yohsuke Yanase	Masaki Tabuchi
  Akihiko Yamauchi	Tetsuya Higami

  A 61-year-old man underwent thoracic aortic graft replacement and abdominal aortic graft replacement because of a dissecting aneurysm. He presented with a ruptured residual dissecting thoraco-abdominal aortic aneurysm and underwent emergency thoraco-abdominal aortic graft replacement in February 2007. An inverted bifurcated graft was fashioned by cutting one of the two graft legs and creating an elliptical patch, like a cobra-head. In order to prevent paraplegia after the operation, it was necessary to shorten the duration of spinal cord ischemia. Once the elliptical patch was sutured to the orifices of the internal costal arteries with running sutures, selective intercostal arterial perfusion was initiated by using a cardiopulmonary bypass. After the operation, he did not suffer paraplegia.
    Jpn. J. Cardiovasc. Surg. 38:273-275（2009）
• Steroid Therapy in a Surgical Treated Case of Ventricular Septal Defect with Congenital Adrenocortical Insufficiency S. Oozawa et al.……276
  Steroid Therapy in a Surgical Treated Case of Ventricular Septal Defect with Congenital Adrenocortical Insufficiency

  Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan）

  Susumu Oozawa	Shingo Kasahara	Yasuhiro Kotani
  Shunji Sano

  A very rare case of congenital adrenocortical insufficiency accompanied with ventricular septal defect, is presented. Surgical treatment together with glucocorticoid replacement therapy was performed. The patient, a 4-month-old girl with congenital adrenocortical insufficiency, had been treated with a long-term adrenocortical hormones replacement. Surgical treatment for ventricular septal defect was applied in order to reduce the risk of heart failure. The administration dose of glucocorticoid was determined according to the body surface area and chronologic change of serum cortisol. Following the surgical treatment, and with adequate glucocorticoid replacement, the patient showed a good clinical outcome. In conclusion, we showed a beneficial treatment protocol with adequate glucocorticoid replacement in open heart surgery for a case of congenital adrenocortical insufficiency.
    Jpn. J. Cardiovasc. Surg. 38:276-279（2009）
• The Efficacy of Linezolid for Methicillin-resistant Staphylococcus aureus Infectious Endocarditis F. Kuwabara et al.……280
  The Efficacy of Linezolid for Methicillin-resistant Staphylococcus aureus Infectious Endocarditis

  （Department of Cardiovascular Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan, and Department of Cardiovascular Surgery, Toyota Kosei Hospital*, Toyota, Japan）

  Fumiaki Kuwabara	Yuichi Hirate	Shunsuke Mori
  Akira Takanohashi	Kei Yagami	Masato Usui
  Yoshiya Miyata	Masaharu Yoshikawa*

  We report a case of methicillin-resistant Staphylococcus aureus（MRSA）infectious endocarditis（IE）which was successfully treated with linezolid（LZD). The patient was a 44-year old woman. She was referred to our hospital because of fever of unknown origin. MRSA was detected from blood cultures and echocardiography revealed vegetation on the right coronary cusp of the aortic valve. She was diagnosed with MRSA endocarditis according to the Duke criteria, and was immediately give vancomycin（VCM）and isepamicin. Sixteen days after administration of VCM, she had a progressively increasing skin rash. It was considered a side effect of antibiotics and VCM was replaced with teicoplanin（TEIC). Eventually, LZD was given to her at 22 days after hospitalization because TEIC was not effective. LZD alleviated the fever and diminished the signs of vasculitis due to endocarditis within a week. LZD was continued for 4 weeks with cardiac failure medically controlled, and she underwent aortic valve replacement using a mechanical prosthetic valve. LZD was injected just before the operation and continued for 15 days postoperatively, followed by oral administration of levofloxacin. She was discharged 35 POD and no recurrence of the infection had been observed at 1 year after the surgery. LZD could be an alternative therapy for MRSA endocarditis, but further examinations are warranted to determine the most appropriate regimen.
    Jpn. J. Cardiovasc. Surg. 38:280-283（2009）
• Two Cases of Accessory Mitral Valve Tissue M. Motohashi et al.……284
  Two Cases of Accessory Mitral Valve Tissue

  （Department of Cardiovascular Surgery, Hakodate Central Hospital, Hakodate, Japan, Department of Cardiovascular Surgery, Hokkaido University Hospital*, Sapporo, Japan, and St. Lukes International Hospital**, Tokyo, Japan）

  Masatoshi Motohashi	Kimitaka Tasai	Takehiro Kubota
  Yoshiro Matsui*	Kouhei Kawazoe**

  We experienced 2 cases of accessory mitral valve tissue（AMVT). Case 1:A 56-year-old man was admitted with aortic regurgitation. Transthoracic and transesophageal echocardiography revealed AMVT with no left ventricular outflow tract obstruction. The patient underwent a successful aortic valvuloplasty. AMVT was carefully excised, because we suspected AMVT might be the cause of recurrent aortic regurgitation and left ventricular outflow tract obstruction with aging. Case 2:A 63-year-old woman was admitted with mitral regurgitation due to infective endocarditis. During medical treatment, transthoracic and transesophageal echocardiography revealed membranous structure in the left atrium uneffected by antibiotics. Mitral valvuloplasty and resection of membranous structure was performed. The membranous structure was not vegetation and had no relationship to mitral regurgitation. Pathological examination proved AMVT. To our knowledge, this is the first report of AMVT in left atrium in an adult.
    Jpn. J. Cardiovasc. Surg. 38:284-288（2009）
• Left Subclavian Artery Arising from Kommerell’s Diverticulum of a Left High Aortic Arch M. Usui et al.……289
  Left Subclavian Artery Arising from Kommerell’s Diverticulum of a Left High Aortic Arch

  （Department of Cardiovascular Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan, Department of Cardiovascular Surgery, Nagoya Daini Red-Cross Hospital*, Nagoya, Japan, and Department of Cardiovascular Surgery, Nagoya University School of Medicine**, Nagoya, Japan）

  Masato Usui	Kazuyoshi Tajima*	Keisuke Tanaka**
  Sachie Terazawa*	Noritaka Okada*	Yoshiyuki Takami*
  Yoshimasa Sakai*

  A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm（50mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell’s diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.
    Jpn. J. Cardiovasc. Surg. 38:289-292（2009）
• Successful Surgical Treatment of Aortic Valve Endocarditis with a Pseudoaneurysm of Ascending Aorta T. Mishima et al.……293
  Successful Surgical Treatment of Aortic Valve Endocarditis with a Pseudoaneurysm of Ascending Aorta

  （Department of Cardiovascular Surgery, Tachikawa Medical Center, Nagaoka, Japan）

  Takehito Mishima	Kazuo Yamamoto	Masahiro Sato
  Akifumi Uehara	Koki Takizawa	Tsutomu Sugimoto
  Shinpei Yoshii	Shigetaka Kasuya

  A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.
    Jpn. J. Cardiovasc. Surg. 38:293-296（2009）
• A Nonagenarian with Ruptured Common Iliac Artery Aneurysm and Cardiopulmonary Arrest N. Kawai et al.……297
  A Nonagenarian with Ruptured Common Iliac Artery Aneurysm and Cardiopulmonary Arrest

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

  Norikazu Kawai	Hisato Takagi	Hideaki Manabe
  Shin-nosuke Goto	Takuya Umemoto

  A 95-year-old man suffered repeated episodes of loss of consciousness. Ruptured abdominal aortic aneurysm with giant retroperitoneal hematoma was diagnosed by computed tomography scans, and was referred to our hospital for surgical management. As he was about to be transported cardiopulmonary arrest developed, and emergency operation was started under resuscitation for pulseless electrical activity condition. We found a left common iliac artery aneurysm intraoperatively. We improved his hemodynamics by clamping the infrarenal abdominal aorta, and performed replacement of the left common iliac artery with a tube graft as quickly as possible. We inserted an intestinal drainage tube because of the expected high intraperitoneal pressure which caused by marked edema of the intestinal tract. He was weaned from respiratory support on the 5th postoperative day. He could walk on his own and was successfully discharged on the 28th postoperative day.
    Jpn. J. Cardiovasc. Surg. 38:297-299（2009）