Japanese Journal of Cardiovascular Surgery Vol.38, No.6

Evaluation of Graft Selection and Design to Improve Long-Term Results of Coronary Artery Bypass Grafting

（Division of Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan）

Hiroshi Baba	Shinji Ogawa	Syunsuke Fukaya
Hideki Kitamura	Masakazu Aoki	Masashi komeda
Yasuhide Ookawa

To improve the long-term clinical results of coronary artery bypass grafting, we evaluated our graft selections and the designs that were used, in relation to the quality of the anastomoses and patient backgrounds. We retrospectively reviewed the records of 505 patients who underwent isolated coronary artery bypass grafting involving more than 3 vessel reconstructions between May 1999 and March 2007. Neither the selection of a saphenous vein graft nor that of an internal thoracic artery graft was a statistically significant cardiac event factor. The cardiac event-free rates（at 1 and 5 years）according to anastomotic site were as follows:a）92.9% and 76.6% for a radial artery graft and 93.2% and 83.9% for a saphenous vein graft at the right coronary artery;b）93.0% and 70.3% for a radial artery graft and 95.1% and 80.4% for a saphenous vein graft at the distal right coronary artery;c）94.5% and 77.8% for a left internal thoracic artery graft and 93.0% and available for a right internal thoracic artery graft at the left anterior descending artery;d）96.5% and 79.8% for a radial artery graft, 93.0% and 78.0% for a saphenous vein graft, and 91.3% and 75.6% for an internal thoracic artery graft at the left circumflex artery. Significant cardiac event factors were dialysis（risk ratio, 5.28;p＜0.001), the use of a right gastroepiploic artery graft as the inflow blood vessel of a radial artery graft（risk ratio, 5.75;p＝0.02), and off-pump coronary artery bypass grafting（risk ratio, 1.62;p＝0.03). As a tendency toward more frequent early-stage cardiac events among patients with radial artery grafts was confirmed, careful follow-up is important for this group of patients. Right gastroepiploic artery grafts should be chosen carefully with full consideration of the anastomotic site quality and the flow demand, as the blood supply capability of such grafts is limited. For dialysis patients, although the mid-term clinical results are still being evaluated, a saphenous vein grafts have bwer early-stage of cardiac events. In younger patients, off-pump bypass is not the only treatment method available, and revascularization with extracorporeal circulation can reliably achieve good long-term results. To improve the long-term clinical results for coronary artery bypass grafts, graft selection and design should be carefully considered on a case-by-case basis. The quality of the anastomotic site and the patient background are important factors, especially with regard to the selection of a saphenous vein graft or a right gastroepiploic artery graft. A radial artery graft should be selected for use in relatively young patients because of its superior patency. Off-pump bypass may not necessarily be the treatment of choice in some cases because revascularization using extracorporeal circulation can reliably achieve better long-term results.
  Jpn. J. Cardiovasc. Surg. 38:355-360（2009）

Keywords：coronary artery bypass grafting, graft selection, graft design

Successful Treatment of Left Ventricular Pseudoaneurysm after Felt Repair for Left Ventricular Free Wall Rupture Associated with Acute Myocardial Infarction

（Department of Cardiovascular Surgery, Sunagawa Medical Center, Sunagawa, Japan） Shunsuke Ohori Masahiro Miyajima Akihiko Sasaki

A 70-year-old man who had undergone felt repair for a left ventricular free wall rupture associated with acute myocardial infarction at age 66. A computed tomography at 4 years postoperatively showed left ventricular pseudoaneurysm and a 1-cm perforating hole. A patch closure with a Dacron patch was performed using cardiopulmonary bypass under ventricular fibrillation through a left thoracotomy. The postoperative course was uneventful and he was discharged on the 18th postoperative day.   Jpn. J. Cardiovasc. Surg. 38:361-363（2009） Keywords：acute myocardial infarction, left ventricular free wall rupture, left ventricular pseudoaneurysm

Surgical Treatment of Bland-White-Garland Syndrome in an Adult Patient

（Department of Cardiovascular Surgery, Komoro Kousei General Hospital, and First Department of Surgery, Toyama University*, Toyama, Japan） Hidetoshi Furuta Shigeyuki Yamashita Keijyu Kotoh*

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly, known as Bland-White-Garland（BWG）syndrome. Most patients with this anomaly require surgical intervention early in life, and it is extremely rare that patients reach middle age without any symptoms. We report the surgical treatment of a BWG syndrome in an adult patient. A 51-year-old man was admitted because of congestive heart failure and atrial fibrillation. Coronary catheterization revealed an anomalous origin of the left coronary artery from the pulmonary trunk and aneurysm of the right coronary artery. The patient was treated with a new technique using an internal tunnel created in the left side main pulmonary artery with a pericardial patch roll. A bypass with an artificial graft was made between this pericardial roll and the ascending aorta. Replacement of the aneurysm of the right coronary artery was also performed. The post operative course was uneventful. The postoperative CT showed the successful results of this operation.   Jpn. J. Cardiovasc. Surg. 38:364-367（2009） Keywords：anomalous origin of the left coronary artery from the pulmonary artery, BWG syndrome, giant right coronary artery aneurysm

A Surgical Case of Kommerell’s Diverticulum with a Right-Sided Aortic Arch

（Division of Organ Regeneration Surgery, Faculty of Medicine, Tottori University, Yonago, Japan, and Department of Cardiovascular Surgery, National Hospital Organization Hamada Medical Center*, Hamada, Japan） Shingo Harada Yoshinobu Nakamura Akira Marumoto Munehiro Saiki Shingo Ishiguro* Motonobu Nishimura

A 51-year-old man, with an abnormal shadow on chest X-ray film, was found to have a right-sided aortic arch with mirror-image branching and Kommerell’s diverticulum. Neither congenital heart anomalies nor vascular ring was observed. We performed descending aorta replacement with a HemashieldTM 24-mm graft, because the trachea and esophagus were compressed by the diverticulum, and to eliminate the risks of aneurysmal change or rupture. The operation was performed through right thoracotomy, and with total CPB under deep hypothermic circulatory arrest. The patient was discharged on the 18th postoperative day. This is rare adulthood case of right aortic arch with Kommerell’s diverticulum and no anomalies in the heart.   Jpn. J. Cardiovasc. Surg. 38:368-371（2009） Keywords：right aortic arch, Kommerell’s diverticulum

False Aneurysm in the Right Groin due to Disruption of a Knitted Dacron Prosthesis

（Department of Cardiovascular Surgery, Aomori Rousai Hospital, Hachinohe, Japan） Masaharu Hatakeyama Yuichi Ono Hiroyuki Itaya

A 75-year-old man was admitted to our hospital with a pulsatile mass in the bilateral groin. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 20 years previously for arteriosclerosis obliterans. Computed tomography demonstrated an aneurysm near the distal anastomosis of the graft. Based on a clinical diagnosis of a non-anastomotic aneurysm, an operation was performed. When the right aneurysm was incised, it was found that the anastomosis of the graft to the common femoral artery was intact and that the graft itself had a defect, 1.5cm in size near the distal anastomosis of the graft. The final diagnosis of the right groin aneurysm was a non-anastomotic false aneurysm due to prosthetic graft failure. The left groin aneurysm was a true aneurysm due to arteriosclerosis. After resection of the bilateral aneurysm, graft interposition with an expanded polytetrafluoroethylene（ePTFE）graft was successfully performed. Generally, arterial grafts below the groin are subject to high levels of mechanical stress, and graft failure is not uncommon. Vascular surgeons should keep in mind that graft failure is not rare in patients with long-standing prosthetic graft.   Jpn. J. Cardiovasc. Surg. 38:372-375（2009） Keywords：prosthetic graft failure, non-anastomotic aneurysm, false aneurysm

A Case of Ruptured Thoracic Aortic Aneurysm Requiring Two-Stage Sternal Closure due to Posterior Mediastinal Hematoma

（Department of Cardiovascular Surgery, Iwate Prefectural Central Hospital, Morioka, Japan） Yukihiro Hayatsu Koichi Nagaya Kei Sakuma Mitsuhide Kakihata Susumu Nagamine

A 70-year-old man with severe chest pain was transferred to our hospital by ambulance. Computed tomography revealed a ruptured thoracic aortic aneurysm and massive bleeding into the posterior mediastinum. Emergency total aortic arch replacement was performed through median sternotomy. However sternal closure induced severe hypotension because the heart was elevated anteriorly by the posterior mediastinal hematoma. The hematoma could not be eliminated fully so the sternum was kept open at the first operation followed by delayed sternal closure 3 days after the operation. After that, the postoperative course was uneventful and the patient was discharged on postoperative day 43.   Jpn. J. Cardiovasc. Surg. 38:376-379（2009） Keywords：ruptured thoracic aortic aneurysm, posterior mediastinum hematoma, two-stage sternal closure

Mitral Valve Repair in a Patient with Partial Rupture of the Posterior Papillary Muscle after Acute Myocardial Infarction

（Department of Cardiovascular Surgery, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan） Takeichiro Nakane Takahide Takeda Naoki Kanemitsu Masaki Aota Yutaka Konishi

Papillary muscle rupture after acute myocardial infarction（AMI）is an infrequent but fatal complication. We report a case of mitral valve repair performed in a patient with partial papillary muscle rupture after AMI. An 85-year-old man was admitted to our hospital for AMI with cardiac shock. Emergency coronary angiography revealed triple-vessel disease, and percutaneous coronary intervention for the culprit lesion of the left circumflex artery was successfully performed. Eleven days after the onset of the AMI, the pulmonary artery pressure abruptly increased to 60 mmHg and a pansystolic murmur was detected. Transesophageal echocardiography showed severe mitral regurgitation（MR）with flail in the A1-A2 region of the anterior mitral leaflet. We demonstrated erratic motion of the ruptured anterior head in the left ventricle, and this was diagnosed as partial rupture of the posterior papillary muscle. Intra-aortic balloon pumping（IABP）was performed to maintain the systemic circulation. Four days after the onset of acute MR（15 days following AMI), we performed mitral valve repair with coronary artery bypass grafting. We reattached the ruptured head to the viable posterior head with pledget sutures and performed annuloplasty using Carpentier-Edwards classical ring M28. Postoperative echocardiography showed no MR, and the patient was uneventfully discharged on the 45th postoperative day.   Jpn. J. Cardiovasc. Surg. 38:380-384（2009） Keywords：acute myocardial infarction, papillary muscle rupture, partial papillary muscle rupture, mitral regurgitation, mitral valve repair

A Case of Mitral Valve Stenosis and Tricuspid Valve Regurgitation Accompanied by Metal Allergy Treated with Mitral Valve Replacement and Tricuspid Valve Annuloplasty

（Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan） Yu Shomura Yukikatsu Okada Michihiro Nasu Hiroshi Fujiwara Shigeru Komori Mikito Inouchi Yasuhisa Ozu Takashi Hashimoto

A 66-year-old woman who had percutaneous mitral valve commissurotomy 12 years before was admitted complaining of dyspnea on effort. Echocardiography showed severe mitral stenosis and regurgitation, and moderate tricuspid regurgitation associated with atrial fibrillation. Based on her past history we suspected allergy to metal, and skin patch tests showed a positive reaction to zinc, manganese, nickel, cobalt, dichromate, stainless steel, titanium alloys, and nickel-chromium-cobalt alloys. We selected an artificial organ which would not cause an allergic reaction. The St. Jude Medical standard cuff mechanical valve was the only compatible prosthetic valve. Anterolateral right thoracotomy, instead of median sternotomy, was selected. Mitral valve replacement with a 27-mm St. Jude Medical standard cuff mechanical valve and tricuspid valve annuloplasty with a 27-mm Duran flexible band were performed. Her postoperative course was uneventful. She is doing well without any allergic symptom 18 months after the surgery.   Jpn. J. Cardiovasc. Surg. 38:385-388（2009） Keywords：metal allergy, prosthetic valve, prosthetic ring for annuloplasty, patch test

Tranexamic Acid Reduces Bleeding during Off-Pump Coronary Artery Bypass Grafting in a Patient on Clopidogrel

（Department of Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka, Japan） Hidehiko Iwahashi Tadashi Tashiro Noritsugu Morishige Yoshio Hayashida Nobuhisa Ito Kazuma Takeuchi Masaru Nishimi Go Kuwahara Yuta Sukehiro

A 72-year-old man was admitted to a local hospital with symptoms of unstable angina pectoris. He was given Clopidogrel for acute coronary syndrome. Coronary angiography showed left main trunk and three-vessel disease. He was then admitted to our hospital due to a sudden onset of unstable angina following shock during the PCI procedure. We performed emergency off-pump coronary artery bypass grafting（OPCAB). He received 10mg/kg/h tranexamic acid during the operation. He also received 2,000U ascorbic acid at the start of surgery and 2,000U after undergoing anastomoses of the coronary artery. Postoperatively, only some minor bleeding was observed. Tranexamic acid and Ascorbic acid reduce bleeding, and transfusion requirements of packed red blood cells, platelets, and the total blood units in patients on Clopidogrel who undergo emergency OPCAB.   Jpn. J. Cardiovasc. Surg. 38:389-393（2009） Keywords:DES, OPCAB, Clopidogrel, Tranexamic acid, Ascorbic acid

Left Ventricular Outflow Pseudoaneurysm after Aortic Valve Replacement for Active Infective Endocarditis

（Department of Surgery, Yokohama City University, Yokohama, Japan） Tomoki Choh Shinichi Suzuki Tomoyuki Minami Hideyuki Iwaki Yukihisa Isomatsu Munetaka Masuda

A 56-year-old man, who underwent aortic valve replacement with a stentless artificial valve for aortic valve endocarditis at age 52, found to have left ventricular outflow pseudoaneurysm by transthorasic echocardiography, transesophageal echocardiography and enhanced computed tomography. We repaired the pseudoaneurysm, combined with valve re-replacement. Left ventricular outflow pseudoaneurysm is a rare disease, and is often associated with active endocarditis. Transesophageal echocardiography and CT scan are useful to diagnose this disease, especially to rule out annular abscess. Operative indication is recommended soon after the diagnosis was made to prevent rupture of pseudoaneurysm, or development of either mitral regurgitation or coronary ischemia due to compression from the pseudoaneurysm. Combined aortic valve replacement, with or without mitral valve replacement is necessary to repair the pseudoaneurysm.   Jpn. J. Cardiovasc. Surg. 38:394-397（2009） Keywords：infective endocarditis, aortic valve replacement, left ventricular outflow pseudoneurysm

Modified Aortic Root Remodeling Combined with Aortic Valve Repair Technique for Severe Aortic Regurgitation Resulting from Prolapse of the Right Coronary Cusp and Aortic Root Dilatation

（Department of Cardiovascular Surgery, Heart Center, St Luke’s International Hospital, Tokyo, Japan） Manabu Yamasaki Sunao Watanabe Kohei Abe Michiko Uenishi Kohei Kawazoe

A 70-year-old man who had been followed up in our outpatient clinic for mild aortic regurgitation underwent curative surgery for progression of the regurgitation due to a prolapsed right coronary cusp, associated with annular dilatation and aortic root aneurysm formation. The Operation consisted of subvalvular circular annuloplasty to reduce the size of the aortic annulus, adjustable leaflet suspension for the prolapsed right coronary cusp, and modified aortic root remodeling, which replaced the Valsalva sinus of both non and right coronary cusps while sparing the Valsalva sinus of the left coronary cusp. Coronary artery bypass grafting was additionally performed for the 90% stenosis of the proximal right coronary artery segment. The postoperative course was uneventful with no need of blood transfusion. He was discharged from the hospital 10 days postoperatively. This combination of valvuloplasty with valve-sparing aortic root reconstruction procedure can be useful.   Jpn. J. Cardiovasc. Surg. 38:398-401（2009） Keywords：aortic valve repair, modified aortic root remodeling