Japanese Journal of Cardiovascular Surgery Vol.39, No.3

Originals

  • Strategies, Risks, and Outcomes in Cardiac and Aortic Reoperations Y. Takami et al.……105
    Strategies, Risks, and Outcomes in Cardiac and Aortic Reoperations

    （Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan）

    Yoshiyuki Takami Kazuyoshi Tajima Hisaaki Munakata
    Makoto Hibino Kei Fujii Noritaka Okada
    Yoshimasa Sakai
    Cardiovascular reoperations involve high-risk because of adhesions. We examined the strategies and clinical outcomes of the reoperations in our institute. From January 2003 to December 2008, 52 patients underwent reoperations, accounting for 4.5% of all adult patients. The duration from the previous surgery was 10.1±9.3 years. Reoperations were performed due to infection（n＝10), after valve surgery（n＝16), after coronary surgery（n＝9), due to Marfan syndrome（n＝3), after aortic surgery（n＝7), after congenital surgery（n＝4), and for other reasons. In the reoperations, the same surgical site was exposed in 65%, the femoral vessels were exposed before re-sternotomy in 77%, the inflow was on the ascending aorta in 35%, and cardiopulmonary bypass was initiated before re-sternotomy in 37%. Systemic cooling was needed in 4 patients and some maneuvers for patent internal thoracic artery grafts in 6 patients. The operation time of 9.6±2.5 h and the cardiopulmonary bypass time of 295±111 min, respectively. We experienced intraoperative injuries in 16 patients（31%). Platelet transfusion was needed in 90% and a second CPB in 15%. Postoperative complications included hemorrhage（14%), infection（13%), stroke（4%), respiratory failure（44%), and renal failure（1%). The hospital mortality was 7.7%（4/52）due to uncontrolled infection, liver failure, pulmonary hemorrhage, and left ventricular rapture. The 2-year survival rate was 83.1% with the mean follow-up of 24±18 months. In conclusion, although the risk of injuries at re-sternotomy was not high, limited surgical field due to adhesions resulted in fatal injuries and in the cardiac reoperations we experienced. We need to improve our strategies for further reduction in mortality and morbidities in reoperations.
      Jpn. J. Cardiovasc. Surg. 39:105-110（2010）

    Keywords：cardiovascular reoperation, redo, re-sternotomy, injuries

Case Reports

  • Abdominal Aortic Aneurysm Associated with Horseshoe Kidney S. Takago et al.……111
    Abdominal Aortic Aneurysm Associated with Horseshoe Kidney

    （Department of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan）

    Shintaro Takago Hiroshi Ohtake Go Watanabe
    We describe the case of an 83-year-old woman who underwent surgical repair for abdominal aortic aneurysm with horseshoe kidney. Preoperative computed tomography（CT）scans showed the presence of not only the principal bilateral renal arteries but 2 accessory renal arteries originating from the right common iliac artery. The left accessory renal artery had 2 branches supplying each of the lower poles of the kidneys. We performed open surgery for artificial graft replacement by dividing the isthmus. The isthmus was formed of fibrous connective tissue therefore we dissected the isthmus sharply and sutured edges. A urinary fistula was absent. Since supply to the right renal lower pole via the left accessory artery was negligible, the artery was ligated. We performed this procedure safely and achieved a successful outcome.
      Jpn. J. Cardiovasc. Surg. 39:111-113（2010）

    Keywords：abdominal aortic aneurysm，horseshoe kidney
  • Right Ventricular Outflow Obstruction due to Huge Un-ruptured Aneurysm of the Sinus of Valsalva in Two Elderly Patients T. Choh et al.……114
    Right Ventricular Outflow Obstruction due to Huge Un-ruptured Aneurysm of the Sinus of Valsalva in Two Elderly Patients

    （Department of Surgery, Yokohama City University, Yokohama, Japan, and Present address:Department of Cardiovascular Surgery, Saiseikai Yokohama-shi Nanbu Hospital*, Yokohama, Japan）

    Tomoki Choh* Shinichi Suzuki Tomoyuki Minami
    Yukihisa Isomatsu Munetaka Masuda
    A sinus of Valsalva aneurysm is a comparatively rare disease, and it has almost no symptoms unless this is rupture, whereas aortic insufficiency, myocardial ischemia and heart failure might be associated with un-ruptured aneurysm of the sinus of Valsalva. We encountered 2 elderly patients（71 years old and 83 years old）with huge un-ruptured aneurysm of the sinus of Valsalva which causes right ventricular outflow tract obstruction. The orifice of the aneurysm of the sinus of Valsalva was closed using ePTFE patches in the both cases. Plication of aneurysm was attempted in both cases, but it failed in case 1 due to undetermined border of the aneurysm on the right side of the heart. Case 2 was required concomitant aortic valve replacement with a bioprosthesis due to associated aortic regurgitation. The repair of un-ruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract obstruction can be performed safely and effectively even in elderly patients.
      Jpn. J. Cardiovasc. Surg. 39:114-117（2010）

    Keywords：Valsalva aneurysm, right ventricular outflow tract obstruction
  • A Case of Prosthetic Valve Dysfunction Early after Surgery Using a Mosaic Bioprosthesis T. Shojima et al.……118
    A Case of Prosthetic Valve Dysfunction Early after Surgery Using a Mosaic Bioprosthesis

    （Department of Cardiovascular Surgery, St. Mary’s Hospital, Kurume, Japan, and Department of Cardiovascular Surgery, Munakata Suikoukai General Hospital*, Fukutu, Japan）

    Takahiro Shojima Hiroshi Yasunaga Naofumi Enomoto*
    Hideki Sakashita Takeshi Oda Yukio Hosokawa
    Kageshige Todo
    An 81-year-old man underwent aortic valve replacement with a 21-mm Medtronic Mosaic porcine bioprosthesis for the treatment of bicuspid aortic valve stenosis. In addition to the appearance of chest discomfort on effort and a new diastolic murmur, echocardiography performed 2 years and 3 months after the surgery showed a high pressure gradient across the bioprosthetic valve and a reduction in the valve orifice area. Prosthetic valve dysfunction was diagnosed. During a repeat operation, 2 large tears on the left cusp and a subvalvular overgrown abundant pannus were observed, and the bioprosthetic valve was replaced with a 19-mm On-X mechanical heart valve. On analysis of the explant bioprosthesis, the right non-coronary stent post was bent outwards by approximately 9°, it compressed the left cusp by pulling the left right and left non-coronary stent posts closer together, thus altering the leaflet geometry and function. We speculated that pannus formation had resulted from turbulent blood flow caused by impaired or altered leaflet function. The 2 large tears appeared to be the result of contact with the bias cloth secondary to the stent distortion.
      Jpn. J. Cardiovasc. Surg. 39:118-121（2010）

    Keywords：Mosaic bioprosthesis, prosthetic valve dysfunction, re-valve replacement
  • Pulmonary Trunk Aneurysm with Ascending Aortic Aneurysm, Concomitant with Bilateral Semilunar Valve Insufficiency M. Sugawara et al.……122
    Pulmonary Trunk Aneurysm with Ascending Aortic Aneurysm, Concomitant with Bilateral Semilunar Valve Insufficiency

    （Department of Cardiovascular Surgery, Japanese Red Cross Nagaoka Hospital, Nagaoka, Japan）

    Masaaki Sugawara Fumiaki Oguma Hiroyuki Hirahara
    Chizuo Kikuchi
    Simultaneous pulmonary trunk and ascending aortic aneurysms are very rare, and the role of surgery in this entity is not well defined. We report a rare case of aneurysm of both the pulmonary trunk and the ascending aorta, associated with pulmonary and aortic valve insufficiency in a 17-year-old boy. Cardiac disease had been diagnosed at the age of 5, and at that time, pulmonary and aortic valve insufficiency were found by ultrasound cardiography（UCG). At regular follow-up, both cardiac valve regurgitation and the dilatation of the aneurysm gradually increased. A recent computed tomographic scan revealed that the ascending aortic aneurysm was 55 mm and the pulmonary trunk aneurysm was 60mm. A UCG also showed severe aortic valve regurgitation and moderate pulmonary valve regurgitation with no pulmonary hypertension. Surgical repair was performed successfully. The aortic valve was replaced with a mechanical valve. The dilated ascending aortic aneurysm was excised and replaced with a Dacron graft. The pulmonary trunk aneurysm was incised longitudinally. The pulmonary valve was tricuspid, and no organic leaflets change was observed. Pulmonary valvuloplasty by commissure plication of the prolapsed cusps was performed. A large portion of the anterior pulmonary aneurysm wall was excised and plicated to reduce the radius diameter. The pathology of the aneurysm wall showed infiltration of inflammatory cells in the tunica media, fragmentation and decrease of elastic fiber, loss of muscular tissue, and increase in collagen fibers. No cystic medial necrosis was observed in the pathologic specimen. The postoperative course was uneventful, and there were no adverse events or complications at 2 years follow-up. The following image study revealed the normal size of the great vessels.
      Jpn. J. Cardiovasc. Surg. 39:122-125（2010）

    Keywords：pulmonary trunk aneurysm, aortic aneurysm, aneurysmorrhaphy, aortic valve replacement, pulmonary valvuloplasty
  • Embolization of an Atraumatic Rupture Occurring in the Internal Thoracic Artery R. Seguchi et al.……126
    Embolization of an Atraumatic Rupture Occurring in the Internal Thoracic Artery

    （Department of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan）

    Ryuta Seguchi Noriyoshi Yashiki Hiroki Kato
    Takeshi Takagi Ko Yoshizumi Shohjiro Yamaguchi
    Hiroshi Ohtake Go Watanabe
    We report the findings in a 75-year-old woman who was given diagnosis of rupture of the internal thoracic artery（ITA）and was successfully treated by coil embolization. The patient suddenly felt chest pain, and a chest CT revealed a mediastinal hematoma. She was suspected to have an acute aortic dissection, and therefore transferred to our hospital. Upon careful examination, a CT showed a hematoma in the superior mediastunum and the extravasation of the left internal thoracic artery. Emergency coil embolization was thus performed to stop the bleeding. After the embolization, no further hemorrhaging was observed. The patient was uneventfully discharged in a healthy state 2 weeks later. Rupture of the internal thoracic artery is rare. However, it is important to include this potential disease in the differential diagnosis when encountering a patient presenting with an atraumatic mediastinal hematoma.
      Jpn. J. Cardiovasc. Surg. 39:126-128（2010）

    Keywords：internal thoracic artery rupture, transcatheter coil embolization
  • Left Ventricular Free Wall Rupture Followed by Papillary Muscle Rupture Combined with Acute Myocardial Infarction J. Kobayashi et al.……129
    Left Ventricular Free Wall Rupture Followed by Papillary Muscle Rupture Combined with Acute Myocardial Infarction

    （Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan）

    Junko Kobayashi Hideo Yoshida Hideyuki Kato
    Toshihiko Suzuki Makoto Mohri Keiji Yunoki
    Kunikazu Hisamochi Osamu Oba
    We described a patient with free wall rupture followed by papillary muscle rupture due to acute myocardial infarction. A 69-year-old man was transferred complaining of transient unconsciousness. His clinical history, electrocardiogram, and chest CT showed myocardial infarction with free wall rupture indicated that several days had passed since the onset. Coronary angiography showed occlusion of the right coronary artery and severe stenosis of the left anterior descending artery. Since cardiac rupture was at inferior wall and hemorrhage wasn’t active, repair of the rupture using fibrin glue and fibrin sheet and coronary artery bypass grafting to the left anterior descending artery was performed without cardiopulmonary bypass. On the 10th postoperative day, his arterial oxygen saturation suddenly deteriorated. Transesophageal echocardiography revealed papillary muscle rupture and severe mitral regurgitation. Emergency mitral valve replacement was performed. After two emergency operations, he gradually recovered and were discharged to home. In three months after discharge, he was admitted again due to congestive heart failure with left ventricular aneurysm at inferior wall and recovered in response of conservative treatment. Surgical experience of double rupture is rare. Based on this case, it may be necessary to perform reperfusion therapy toward even this case of recent myocardial infarction, to prevent papillary muscle rupture. It also may be better to use a patch on free wall rupture to prevent cardiac aneurysm.
      Jpn. J. Cardiovasc. Surg. 39:129-132（2010）

    Keywords：acute myocardial infarction, left ventricular free wall rupture, papillary muscle rupture
  • Surgical Repair in Case of an Elderly Tetralogy of Fallot Y. Chida et al.……133
    Surgical Repair in Case of an Elderly Tetralogy of Fallot

    （Department of Cardiovascular Surgery, Akita Medical Center, Akita, Japan, Department of Cardiovascular Surgery, School of Medicine, Akita University*, Akita, Japan, and Department of Cardiovascular Surgery, Yuri Kumiai General Hospital**, Akita, Japan）

    Yoshifumi Chida Fumio Yamamoto* Hiroshi Yamamoto*
    Kazuyuki Ishibashi* Genbu Yamaura* Keisuke Shiroto*
    Mamika Motokawa* Fuminobu Tanaka* Keiji Seki
    Makoto Matsukawa**
    A 62-year-old woman with the tetralogy of Fallot（TOF）diagnosed at 24 years of age, was admitted with fever and dyspnea. She also had cyanosis and heart failure and was categorized as New York Heart Association（NYHA）functional class IV. Echocardiography showed TOF with a-grade III tricuspid valve regurgitation. Cardiac catheterization revealed major aorto-pulmonary collateral arteries（MAPCAs）for the left upper pulmonary circulation. After coil embolization of MAPCAs to reduce abnormal intracardiac return as well as postoperative left ventricular volume overload, the patient underwent total surgical correction（i.e., right ventricular outflow tract reconstruction using Medtronic FreeStyle Valve and transannular patch, ventricular septal defect closure, and tricuspid annuloplasty). Postoperatively, the patient had a satisfactory course during the 10-year follow-up period with a grade-I NYHA classification. In conclusion, intracardiac repair of TOF in case over 60 years of age can be performed safely by preoperative MAPCAs embolization and subsequent TOF repair with a strategy to abolish pulmonary and tricuspid valve regurgitation.
      Jpn. J. Cardiovasc. Surg. 39:133-136（2010）

    Keywords：tetralogy of Fallot, elderly patient, MAPCA
  • A Case of Hypertrophic Cardiomyopathy with Two Times Thromboembolism and Intraventricular Thrombus K. Koushi et al.……137
    A Case of Hypertrophic Cardiomyopathy with Two Times Thromboembolism and Intraventricular Thrombus

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

    Keitarou Koushi Yasushi Tutumi Osamu Monta
    Yosuke Takahashi Kimitoshi Kitani Tomohiko Sakamoto
    Hirokazu Ohashi
    We present a rare case of a 59-year-old-man with a diagnosis of hypertrophic cardiomyopathy（HCM）complicated with left ventricular thrombus. He was admitted to our hospital because of acute re-occlusion of the right brachial artery. Thrombectomy was performed and reperfusion was obtained. Anti-coagulation therapy was started from that day. Four days after surgery, echocardiography revealed mobile thrombus in left ventricular apical aneurysm that was not detected on admission. An emergency thrombectomy and left ventriculoplasty was performed. The patient was discharged 22 days after surgery in good condition.
      Jpn. J. Cardiovasc. Surg. 39:137-140（2010）

    Keywords：hypertrophic cardiomyopathy, left ventricular aneurysm, left ventricular thrombus, left ventriculoplasty
  • A Patient with Mediastinitis Complicated by Pyrogenic Spondylitis after Coronary Artery Bypass Grafting K. Kohno et al.……141
    A Patient with Mediastinitis Complicated by Pyrogenic Spondylitis after Coronary Artery Bypass Grafting

    （Department of Cardiovascular Surgery, Nishiarai Hospital Heart Center, Tokyo, Japan）

    Koji Kohno Hiroshi Amano Yasushi Kawai
    Yasuo Takeuchi
    A 59-year-old man with myocardial infarction underwent 4-vessel coronary artery bypass grafting. After operation, on the 9th hospital day, fever, dehiscence of the median wound, and pus discharge were observed. Methicillin-resistant Staphylococcus aureus（MRSA）was detected in the wound, and median wound curettage and removal of the sternal bone wire were performed. The infection also involved the substernal area and anterior mediastinum, and a diagnosis of mediastinitis was made. After wound cleansing and antibiotic（vancomycin）administration, inflammatory reactions decreased, and MRSA disappeared from the wound. The wound spontaneously closed, and complete closure required 60 days. On the 75th hospital day, pain from the right shoulder to the neck and numbness in the upper limbs suddenly developed. MRI revealed vertebral body destruction at C5-6, and a diagnosis of cervical osteomyelitis was made. The spinal cord was compressed, and there was a risk of spinal cord injury below the cervical spine. After consultation with orthopedic surgeons, cervical anteroposterior fixation was performed, he improved, and was discharged. We report a patient with MRSA mediastinitis complicated by cervical osteomyelitis who required emergency surgery.
      Jpn. J. Cardiovasc. Surg. 39:141-143（2010）

    Keywords：coronary artery bypass grafting, mediastinitis, pyrogenic spondylitis
  • Heparin Anticoagulation during Cardiopulmonary Bypass for Thoracoabdominal Aorta Replacement in a Patient with a History of Heparin-Induced Thrombocytopenia M. Ohba et al.……144
    Heparin Anticoagulation during Cardiopulmonary Bypass for Thoracoabdominal Aorta Replacement in a Patient with a History of Heparin-Induced Thrombocytopenia

    （Department of Cardiovascular Surgery, Chiba Cardiovascular Center, Ichihara, Japan, and Division of Transfusion Medicine, National Cardiovascular Center*, Osaka, Japan）

    Masanao Ohba Hirokazu Murayama Hiroyuki Kito
    Kozo Matsuo Naoki Hayashida Souichi Asano
    Masao Hirano Shigeki Miyata*
    Immune heparin-induced thrombocytopenia（HIT）is a crucial side effect of heparin therapy. We report the case of a 52-year-old man who was strongly suspected of having HIT after urgent descending aorta replacement. This case required continuous hemodiafiltration（CHDF）anticoagulated with unfractionated heparin（UFH）for acute renal failure after the operation. The patient developed thrombocytopenia and thrombus emphraxis in the circuit on the seventh day and was suspected of having HIT. UFH was ceased and replaced with argatroban. After then, thrombus emphraxis was not seen in the circuit and the platelet count was recovered promptly. He tested positive in an enzyme-linked immunosorbent assay for anti-platelet factor 4/heparin antibodies（anti-PF4/H Abs). Six months later, we found, an expanding thoracoabdominal aortic aneurysm and performed thoracoabdominal aorta replacement. We selected heparin anticoagulation for cardiopulmonary bypass because anti-PF4/H Abs were negative at that time. Thrombus emphraxis was not found during the operation. The patient developed neither thrombocytopenia nor thrombosis in the perioperative period.
      Jpn. J. Cardiovasc. Surg. 39:144-147（2010）

    Keywords：heparin-induced thrombocytopenia（HIT), cardiopulmonary bypass, thoracoabdominal aortic replacement
  • A Case of Abdominal Aortic Aneurysm in Association with Horseshoe Kidney Y. Sotoda et al.……148
    A Case of Abdominal Aortic Aneurysm in Association with Horseshoe Kidney

    （Department of Cardiovascular Surgery, Saisei Yamagata Hospital, Yamagata, Japan）

    Yoko Sotoda Shigeki Hirooka Hiroyuki Orita
    Horseshoe kidney（HSK）occurs in about 0.25% of the population. Coincidence of HSK with abdominal aortic aneurysm（AAA）is rare. We describe a 70-year-old man with an infrarenal AAA coexistence with HSK diagnosed by 3D-CTA. Preoperative 3D-CT and Angiography showed two major renal arteries and an accessory artery arising from the anterior wall of aneurysm. The aneurysm was successfully replaced by knitted Dacron bifurcated graft without resection of the isthmus. The accessory renal artery was reconstructed to the graft. Renal infarction and renal dysfunction did not occur and the postoperative course was uneventful.
      Jpn. J. Cardiovasc. Surg. 39:148-150（2010）

    Keywords：horseshoe kidney, abdominal aortic aneurysm, accessory renal artery
  • Emergency Redo Aortic Root Replacement for Composite Graft Dehiscence due to Aortitis Syndrome in a Child Y. Maekawa et al.……151
    Emergency Redo Aortic Root Replacement for Composite Graft Dehiscence due to Aortitis Syndrome in a Child

    （Department of Surgery Ⅱ, Yamagata University School of Medicine, Yamagata, Japan）

    Yoshiyuki Maekawa Yukihiro Yoshimura Shuji Toyama
    Ryota Miyazaki Yoshinori Kuroda Mitsuaki Sadahiro
    We report a case of 10-year-old woman with aortitis syndrome who had a graft dehiscence at the site of proximal anastomosis 8 months after aortic root replacement. Because she suffered severe chest compression and ST depression was demonstrated on 12 lead ECG, she was admitted on a suspicion of vasospasmic angina. However, transesophageal echocardiogram and CT showed an echo-free space around the previous operated aortic composite graft, so we concluded that a proximal graft dehiscence and bleeding around it was the cause of her severely deteriorated circulatory condition, and emergency redo aortic replacement was planned. After deep hypothermic circulatory arrest was accomplished, selective cerebral perfusion was performed following re-sternotomy. Previous composite graft was detached at the site of proximal anastomosis, and the aortic annulus was friable and edematous. Redo aortic replacement successful. Laboratory findings revealed uncontrollable aortitis syndrome as the etiologic factor of graft dehiscence. Postoperatively, she was complicated with cerebral infarction due to a stuck valve. She was discharged at 56 postoperative day.
      Jpn. J. Cardiovasc. Surg. 39:151-154（2010）

    Keywords：aortitis, Takayasu’s arteritis, graft dehiscence, redo operation
  • A Successful Case of Treatment of Graft Infection by Using Allografts after Ascending Thoracic Aortic Reconstruction T. Nakajima et al.……155
    A Successful Case of Treatment of Graft Infection by Using Allografts after Ascending Thoracic Aortic Reconstruction

    （Department of Traumatology and Critical Care Medicine, Sapporo City General Hospital, Sapporo, Japan, Intensive Care Unit*, and Department of Thoracic and Cardiovascular Surgery**, Sapporo Medical University, Sapporo, Japan）

    Tomohiro Nakajima Noriyasu Watanabe Satoshi Muraki
    Kazushige Kanki Yoshihiko Kurimoto* Tetsuya Higami**
    Thoracic graft infection is a serious complication and has high mortality. We report a case of successful treatment of graft infection after ascending thoracic aortic reconstruction. A 66-year-old woman underwent surgery for DeBakey type I aortic dissection in June 2007. The ascending aorta was replaced with a prosthetic graft. Although her postoperative course was complicated with Methicillin-resistant Staphylococcus aureus（MRSA）mediastinitis, the infection was conservatively controlled by mediastinal lavage and antibiotics. However, she was readmitted in April 2008 due to lumbar pain and high fever, and was diagnosed with infectious spondylitis. Lumbar plastic surgery was performed. During hospitalization, she underwent total systemic examination. The results indicated aneurysm of the ascending aorta. MRSA was detected from culture fluid of her blood. Taken together, the presence of an infected aortic aneurysm was considered possible. Consequently, reconstruction of the ascending aorta using two allografts was performed after removing the prosthetic graft. The postoperative course was uneventful, and she was discharged on the 71st postoperative day. The patient continues to thrive 9 months after the operation. This case of an infected aortic aneurysm repaired with the use of allografts will be reported together with references to the literature.
      Jpn. J. Cardiovasc. Surg. 39:155-158（2010）

    Keywords：allograft, infected aortic aneurysm, reconstruction, acute aortic dissection