Japanese Journal of Cardiovascular Surgery Vol.39, No.2

Review

Case Reports

  • A Case of Off-Pump CABG for Unstable Angina with High-Risk Complications Secondary to Aortitis S. Sumino et al.……60
    A Case of Off-Pump CABG for Unstable Angina with High-Risk Complications Secondary to Aortitis

    （Department of Cardiovascular Surgery, Takase Clinic, Takasaki, Japan, Department of Cardiovascular Surgery, Sagamihara Kyodo Hospital*, Sagamihara, Japan, and Department of Cardiovascular Surgery, Yamato Seiwa Hospital**, Yamato, Japan）

    Satoshi Sumino Minoru Matsuhama Hiroyuki Fujisaki*
    Akihiro Nabuchi**
    A 66-year-old woman suffered from an effort angina attack and visited our clinic. Coronary angiography revealed severe stenosis in the ostium of bilateral coronary arteries. Preoperative computed tomography（CT）demonstrated severe calcification of the aorta and aneurysmal change in the thoracic descending aorta. Off-pump CABG was performed without mechanical cardiac support using composite grafts of the right internal mammary artery and a saphenous vein graft. Graft patency was intraoperatively confirmed by SPY as well as by coronary multi detector-row computed tomography（MDCT）3 months postoperatively.
      Jpn. J. Cardiovasc. Surg. 39:60-64（2010）

    Keywords：aortits, off-pump GABG, unstable angina
  • The Leaving Hospital Program of the Patient with LVAD for Destination Therapy S. Gon et al.…65
    The Leaving Hospital Program of the Patient with LVAD for Destination Therapy

    （Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Japan, Cardiac Surgery, The University of Tokyo Hospital*, Tokyo, Japan, and Graduate School of Medicine Therapeutic Strategy for Heart Failure, The University of Tokyo**, Tokyo, Japan）

    Shigeyoshi Gon Yoshihiro Suematsu Sei Morizumi
    Tsuyoshi Shimizu Takashi Nishimura* Shunei Kyo**
    The left ventricle assist device（LVAD）has become an important therapeutic option in the treatment of acute or chronic heart failure. It is usually used as bridge to transplantation or recovery. At present, destination therapy with LVAD has been a therapeutic option in patients with heart failure in whom transplantation is not indicated. We describe a patient, who received destination therapy with LVAD, and was able to go home temporarily. The patient was a 63-year-old man with low output syndrome after acute myocardial infarction. An LVAD（TOYOBO）was implanted at Oita University Hospital, however the patient suffered from MRSA mediastinitis 6 months later. He and his family wished for him to temporarily go home to Ibaraki. The patient, supported by LVAD, was transferred from Oita to Ibaraki by a regular commercial flight and ambulance. Rehabilitation training involved stretching, in-bed muscle strength training, maintaining a standing position, walking on flat ground with a walker and going up and down ramps. All training was measured at the patient’s home. The patient was out of hospital for 5 hours, and this period was uneventful upon leaving hospital. The patient also took an active part in rehabilitation after discharge. This program can help to improve the quality of life（QOL）of patients with implanted LVADs for destination therapy.
      Jpn. J. Cardiovasc. Surg. 39:65-68（2010）

    Keywords：destination therapy, LVAD, leaving hospital program
  • Successful Endovascular Stent-graft Treatment of a Ruptured Thoracoabdominal Aortic Aneurysm with Coverage of the Celiac Axis T. Hachimaru et al.……69
    Successful Endovascular Stent-graft Treatment of a Ruptured Thoracoabdominal Aortic Aneurysm with Coverage of the Celiac Axis

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

    Tsuyoshi Hachimaru Masazumi Watanabe Satoru Kawaguchi
    Hideki Nakahara
    A 73-year-old woman was referred to our hospital for treatment of a ruptured thoracoabdominal aortic aneurysm（TAAA). Computed tomography（CT）showed a ruptured saccular TAAA（maximum diameter, 70mm）located just above the celiac trunk. The patient chose to undergo endovascular repair because of the high risk associated with conventional repair, so an emergency endovascular stent-graft treatment was performed. The collateral pathway from the superior mesenteric artery（SMA）to the celiac branches via the pancreaticoduodenal arcades was confirmed by selective angiography of the SMA before stent-grafting. The stent-graft was successfully deployed just proximal to the origin of the SMA with intentional coverage of the celiac axis to achieve sealing. Postoperatively, the patient was free from abdominal organ disorder or paraplegia/paraparesis and was discharged from the hospital after 36 days procedure. Follow-up CT scans performed at 1 week, month and 6 months showed patency in the SMA and the celiac branches, and there was no evidence of an endoleak. A less invasive endovascular repair procedure such as this can be an alternative treatment of a ruptured TAAA.
      Jpn. J. Cardiovasc. Surg. 39:69-73（2010）

    Keywords：ruptured thoracoabdominal aortic aneurysm, stent-graft, landing zone, celiac axis, collateral circulation
  • A Case of Therapy for Cardiac Failure in Postoperatively of Atrial Septal Defect K. Tanaka et al.……74
    A Case of Therapy for Cardiac Failure in Postoperatively of Atrial Septal Defect

    （Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan）

    Koyu Tanaka Yohei Okita Masahito Saito
    Kyu Rokkaku Yoshihito Irie Takao Imazeki
    A 62-year-old man had been given a diagnosis of atrial septal defect（ASD）20 years previously, but the condition was left untreated. A heart murmur was detected on a routine health examination, so he visited our institution where a diagnosis of type II ASD and moderate tricuspid regurgitation was given. Cardiac catheterization revealed a pulmonary to systemic flow ratio（Qp/Qs）of 2.9, pulmonary vascular resistance of 3.1 units, and systolic pulmonary artery pressure of 90mmHg. The patient underwent open surgery consisting of a patch closure of the ASD, and tricuspid annuloplasty. His pulmonary arterial pressure rose and his blood pressure dropped, and left cardiac failure developed on postoperative day（POD）2. The administration of catecholamines and a phosphodiesterase（PDE）III inhibitor failed to correct the left cardiac failure. We performed intra-aortic balloon pumping（IABP）immediately, and his hemodynamic condition stabilized. The IABP catheter was removed on POD 10. The postoperative development of circulatory failure suggested that it was almost too late for surgery for ASD. It has been believed that surgery for ASD is relatively safe. However, it seems that, the considering the possible occurrence of postoperative cardiac failure in elderly patients with accompanying pulmonary hypertension, careful postoperative management is necessary.
      Jpn. J. Cardiovasc. Surg. 39:74-77（2010）

    Keywords：atrial septal defect, postoperative left heart failure, intra-aortic balloon pumping
  • A Case of Valve Repair for Active Infective Endocarditis Located in the Tricuspid Valve I. Kigawa et al.……78
    A Case of Valve Repair for Active Infective Endocarditis Located in the Tricuspid Valve

    （Department of Cardiovascular Surgery, Mitsui Memorial Hospital, Tokyo, Japan）

    Ikutaro Kigawa Haruo Yamauchi Sumio Miura
    Sachito Fukuda Takeshi Miyairi
    We report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 35-year-old man with no history of cardiac disease was admitted to our institution for persistent fever. His blood culture was positive for methicillin-sensitive Staphylococcus aureus（MSSA). Echocardiography showed friable vegetations attached to the tricuspid valve with moderate tricuspid regurgitation. No other valves were affected. Chest computed tomography revealed multiple septic pulmonary emboli in both lungs. The infection was uncontrollable, so despite 6 weeks’ of appropriate intravenous antibiotics therapy, he required surgery. Infected lesions had extended to parts of the septal leaflet and the posterior leaflet of the tricuspid valve. Valve repair with the resection-suture technique was performed. Half of the septal leaflet and a part of the posterior leaflet were excised with the vegetations, and the remaining septal leaflet was sutured to the posterior leaflet after annular plication without implanting an artificial ring. The postoperative course was uneventful, without further tricuspid regurgitation or stenosis. He was discharged after additional antibiotic administration for 4 weeks postoperatively, and he has remained free from endocarditis for over 1 year.
      Jpn. J. Cardiovasc. Surg. 39:78-81（2010）

    Keywords：tricuspid valve endocarditis, active endocarditis, tricuspid valve repair, septic pulmonary emboli
  • A Case of Coronary-Pulmonary Artery Fistula after Open-Heart Surgery T. Murase et al.……82
    A Case of Coronary-Pulmonary Artery Fistula after Open-Heart Surgery

    （Department of Cardiovascular Surgery, Odawara Cardiovascular Hospital, Odawara, Japan）

    Toshifumi Murase Susumu Tamura Masashi Yokomuro
    Yasuhiro Ohzeki Kunio Ebine
    A 64-year-old woman with an atrial septal defect（ASD）closure was referred to our hospital;she presented with dyspnea at the time of admission. An echocardiogram showed mitral valve regurgitation, tricuspid valve regurgitation, and a residual ASD shunt. Coronary angiography revealed coronary-pulmonary artery fistulae originating from both the left anterior descending coronary artery and the right coronary artery（RCA). Closure of the coronary-pulmonary artery fistulae was performed in addition to mitral valve replacement, tricuspid valve plasty and ASD closure. The postoperative course was uneventful. Coronary angiography was performed, and some of the contrast medium remained in parts of the RCA fistulae. Ligation of the fistulae and direct closure of the intra-pulmonary openings during cardiopulmonary bypass had to be performed because of complete obstruction of the coronary-pulmonary artery fistulae.
      Jpn. J. Cardiovasc. Surg. 39:82-85（2010）

    Keywords：coronary-pulmonary artery fistulae
  • Repair of Unicuspid Aortic Valve and Mitral Valve Aneurysm Secondary Involved with Intectious Endocarditis S. Watanabe et al.……86
    Repair of Unicuspid Aortic Valve and Mitral Valve Aneurysm Secondary Involved with Intectious Endocarditis

    （Department of Cardiovascular Surgery, Kurashiki General Hospital, Kurashiki, Japan）

    Shun Watanabe Tatsuhiko Komiya Genichi Sakaguchi
    Joji Ito
    A 25-year-old man with a previous diagnosis of congenital bicuspid aortic valve presented with a fever of unknown origin for 3 months. Transthoracic echocardiography revealed vegetation on the mitral valve leaflet. Transesohageal echocardiography revealed severe aortic regurgitation and a mitral valve leaflet aneurysm. Despite intensive antibiotic therapy, his clinical condition did not improve, so he underwent aortic and mitral valve repair. The aortic valve was shown to be unicuspid intraoperatively. We made a new commissure, then mitral valve aneurysm was resected and a new leaflet was made using the pericardium. There was almost no regurgitation seen on postoperative echocardiography.
      Jpn. J. Cardiovasc. Surg. 39:86-89（2010）

    Keywords：intectious endocarditis, mitral valve aneurysm, unicuspid aortic valve
  • Three Cases of Infected Abdominal Aortic Aneurysm and In-Situ Repacement of the Affected Segment with a Prosthesis or Cryopreserved Arterial Homograft M. Uehara et al.……90
    Three Cases of Infected Abdominal Aortic Aneurysm and In-Situ Repacement of the Affected Segment with a Prosthesis or Cryopreserved Arterial Homograft

    （Department of Cardiovascular Surgery, Teine Keijinkai Hospital, and Second Department of Surgery, Sapporo Medical University*, Sapporo, Japan）

    Mayuko Uehara Ryushi Maruyama Akira Yamada
    Katsuhiko Nakanishi Yoshihiko Kurimoto* Fumiyuki Okamoto
    Keisuke Sakai Tetuya Higami*
    We encountered three cases of infra-renal infected abdominal aortic aneurysm in 2007 and 2008. Preoperative blood culture was positive in two of the three patients. All of the patients presented with fever of unknown origin. We replaced the affected segment of the abdominal aorta with a synthetic graft in 1 patient, and with a cryopreserved arterial homograft in the remaining 2 patients. An infected abdominal aortic aneurysm is a life-threatening condition. Diagnosis is often difficult, and emergency surgery may be necessitated by rupture of the aneurysm. Our experience suggests that computed tomography is effective for the diagnosis of infected aneurysms. The most effective surgical technique consists of complete resection of the aneurysm, in-situ replacement of the affected aortic segment with a synthetic graft or homograft, and omental coverage.
      Jpn. J. Cardiovasc. Surg. 39:90-93（2010）

    Keywords：infected abdominal aortic aneurysm, fever of unknown origin, homograft
  • A Surgical Case of Ischemic Cardiomyopathy Evaluated by Multi Detector-Row Computed Tomography Y. Yokoyama and H. Satoh……94
    A Surgical Case of Ischemic Cardiomyopathy Evaluated by Multi Detector-Row Computed Tomography

    （Department of Cardiovascular Surgery, Yotsuba Circulation Clinic, Matsuyama, Japan）

    Yuichiro Yokoyama Harumitsu Satoh
    For patients with advanced heart failure, surgical left ventricular restoration（SVR）is an option usually evaluated by nuclear cardiac imaging, magnetic resonance imaging and ultrasonography. The clinical application of multi detector-row computed tomography（MDCT）has been increasingly extended to evaluate not only coronary artery stenosis, but also cardiac function, myocardial perfusion and viability. We report a successful surgical case of ischemic cardiomyopathy evaluated by MDCT in pre-and post-LVR. A 59-year old man was admitted to our hospital because of worsening heart failure. He had a history of coronary artery bypass grafting after myocardial infarction of the anterior wall at age 45 but had discontinued his medication 5 years previously. Ultrasonography showed poor left ventricular function, massive mitral regurgitation and a floating mural thrombus which required emergency surgery. In addition to conventional coronary angiography, electrographically-gated MDCT clearly described the complex coronary anatomy and stenosis, global and regional left ventricular function, and the relation between the mural thrombus and the scarred myocardium. Thrombectomy, LVR（overlapping type), coronary artery bypass grafting and mitral annuloplasty were performed. Postoperative MDCT showed improvement in left ventricular volume and function in the time-volume analysis, in wall thickness and wall thickening in both the SVR site and remote sites in four-dimensional volumetric imaing. Our case suggests that MDCT can be a valuable tool for the cardiac surgeon.
      Jpn. J. Cardiovasc. Surg. 39:94-98（2010）

    Keywords：ischemic cardiomyopathy, surgical left ventricular restoration, multi detector-row computed tomography
  • Concomitant Repair of Annuloaortic Ectasia, Aortic Regurgitation, and Pectus Excavatum in Marfan Syndrome Y. Nakayama et al.……99
    Concomitant Repair of Annuloaortic Ectasia, Aortic Regurgitation, and Pectus Excavatum in Marfan Syndrome

    （Department of Cardiovascular Surgery, Sendai Cardiovascular Center, Sendai, Japan）

    Yuki Nakayama Akira Shikawa Yoshikazu Ayusawa
    Susumu Hosoda
    Marfan syndrome may include cardiovascular disease co-exising with thoracic deformities. A 24 year-old man given a diagnosis of Marfan syndrome and annuloaortic ectasia（AAE), aortic regurgitation（Ar）and pectus excavatum, was referred to our hospital due to the rapid dilatation of a root aneurysm. Chest computed tomography showed a root aneurysm measuring about 60×55mm in diameter with mild Ar. Moreover, the sternum, which had been displaced in a posterior direction, contacted with the root aneurysm and heart. The heart was deviated to the left, because of compression from the sternum. We performed a concomitant repair of AAE and Ar and pectus excavatum with partial sternal turnover and elevation, and Bentall procedure. First, median skin incision was made, and dissected to the sternum. The ribs and cartilage below the third rib were cut, and the sternum was transected at the two-thirds point. The root aneurysm and heart were visible so it was easier to operate than a post median sternotomy. A cardiopulmonary bypass was established by ascending aortic perfusion, right atrial drainage and pulmonary arterial venting. The Bentall procedure was done using a Carrel patch methods. The removed sternum was formed flat and turned over, and sternum elevation was perfomed using sternal wire, after cutting and removing the excess ribs and costal cartilage. The postoperative course was uneventful with good hemodynamic and respiratory function. Concomitant surgery provides good operative exposure, which can avoid accidental aneurysm laceration, although operation time is longer and operative invasion and bleeding are greater than in staged operations.
      Jpn. J. Cardiovasc. Surg. 39:99-103（2010）

    Keywords：pectus excavatum, annuloaortic ectasia（AAE), Marfan syndrome, partial sternal turn-over and elevation, concomitant operation