Japanese Journal of Cardiovascular Surgery Vol.39, No.5

Surgical Revascularization for the Elderly Patients

（Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan）

Susumu Manabe

Shuichiro Takanashi

Clinical outcomes of CABG for elderly patients have dramatically changed during the last decade. Data from the clinical registries revealed the decrease of in-hospital mortality rate of CABG for elderly patients. Several large-scale comparative studies reported the advantage of CABG to improve long-term outcomes in elderly patients compared with PCI or medical therapy. These findings suggested the need to reconsider our approach to treat ischemic heart disease in the elderly. Hence, this study tries to overview the recent studies investigating the clinical outcomes of CABG for elderly patients.
  Jpn. J. Cardiovasc. Surg. 39:235-241（2010）

Keywords：CABG, elderly patients

Two Cases of Left Ventricular Outflow Tract Obstruction after Rastelli Type Operation for Cardiac Anomalies Associated with Transposed Aorta from the Right Ventricle

（Department of Surgery, Yokohama City University, Yokohama, Japan, and Present address:Cardiovascular Center, Yokohama City University Medical Center*, Yokohama, Japan）

Tomoyuki Minami*	Yusuke Matsuki	Tomoki Choh
Keiichiro Kasama	Hideyuki Iwaki	Shinichi Suzuki
Yukihisa Isomatsu	Munetaka Masuda

Intracardiac repair for cardiac anomalies associated with a transposed aorta from the right ventricle is a technically demanding operation. We present two cases of left ventricular outflow tract（LVOT）obstruction after the use of an ePTFE flat patch to reconstruct the LVOT. Case 1:A 10-year-old boy had undergone the Rastelli operation, VSD enlargement, and intraventricular re-routing using an ePTFE flat patch for repair of the DORV with noncommitted VSD and pulmonary stenosis at the age of 5. Five years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using a part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. Case 2:A 13-year-old girl had undergone a double-switch operation（Senning operation, the Rastelli operation, and intraventricular re-routing by the use of an ePTFE flat patch）for the repair of corrected TGA, PA and VSD at the age of 7. Six years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. We consider that the use of a flat patch for reconstruction of a left ventricular out flow tract in cases with transposition of the aorta from the right ventricle involves a risk of future development of LVOT obstruction.
  Jpn. J. Cardiovasc. Surg. 39:242-245（2010）

Keywords：intraventricular re-routing, left ventricular outflow tract obstruction, DORV, cTGA, ePTFE graft

Successful Repair in Two Cases of Traumatic Tricuspid Regurgitation

（Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara, Japan）

Tomoaki Hirose	Takehisa Abe	Nobuoki Tabayashi
Yoshiro Yoshikawa	Yoshihiro Hayata	Keigo Yamashita
Yoichi Kameda	Shigeki Taniguchi

Traumatic tricuspid regurgitation is a rare cardiovascular event that can follow blunt chest trauma. We report 2 cases of successful repair of traumatic tricuspid regurgitation. Case 1:a 22-year-old man. At 18 years of age, he was involved in a falling accident. At the age of 19, he had an abnormal electrocardiogram and a cardiac murmur pointed out on a medical examination in his university. Echocardiography revealed severe tricuspid regurgitation, and he was referred to our institution for surgery. The operative findings showed some fenestrations in the anterior leaflet of the tricuspid valve. The fenestrations were sutured directly and ring annuloplasty was performed. Case 2:a 54-year-old man. At age 18, he was involved in a falling accident. At age 31, he complained of fatigue and dyspnea. Echocardiography revealed severe tricuspid regurgitation. At age 54, liver dysfunction was discovered. He was referred to our institution for surgical treatment. In the operative findings, the chordae tendineae of the anterior and septal leaflets of the tricuspid valve were ruptured. Tricuspid valvuloplasty was performed using chordal replacement with 2 expanded polytetrafluoroethylene（CV-52®）sutures, edge-to-edge sutures and ring annuloplasty.
  Jpn. J. Cardiovasc. Surg. 39:246-249（2010）

Keywords：traumatic tricuspid regurgitation, tricuspid valvuloplasty, blunt chest trauma

Use of Aortic Valved Grafts for Apico-aortic Conduit Bypass

（Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan, and Department of Cardiovascular Surgery, Saku Central Hospital*, Saku, Japan）

Sojiro Sata	Ryusuke Suzuki	Toshiaki Watanabe
Mai Matsukawa	Keiko Hiroshige	Shunji Osaka
Toshiya Koyanagi	Takahiro Takemura*

We describe the case of a 60-year-old woman with severe aortic stenosis and severe calcification of the thoracic aorta, who underwent an apico-aortic conduit bypass using an aortic valved graft. Because of stenosis of the annulus of the aortic valve and severe calcification of the thoracic aorta（porcelain aorta), we did not perform ordinary aortic valve replacement. Instead, apico-aortic conduit bypass surgery was performed using a St. Jude Medical Aortic Valved Graft（19-20mm:St. Jude Medical, St. Paul, MN, USA）and cardiopulmonary bypass（CPB）surgery was performed using descending aortic perfusion and left pulmonary artery drainage, while the subject was in the right decubitus position. The descending aorta was clamped and a 20-mm graft（Hemashield Platinum;Boston Scientific/Medi-tech, Natick, MA, USA）was sutured to it. Under ventricular fibrillation, the left ventricular apex was circularly resected using a puncher with a diameter identical to that of the 20-mm graft, in order to create a new outflow for the conduit bypass. The graft was sutured to the outflow, and a torus-shaped equine pericardial sheet was used to reinforce the suture line. After recovery of the heartbeat, the aortic valved graft was first sutured to the graft at the outflow and then to the graft at the descending aorta. The CPB time was 285 min and ventricular fibrillation time was 36 min. Therefore, the benefits of using an aortic valved conduit for apico-aortic conduit bypass are reduced operation time, since there is no need to prepare a handmade valve conduit, and easy management of the grafts which are made of the same material.
  Jpn. J. Cardiovasc. Surg. 39:250-253（2010）

Keywords：apico-aortic conduit, porcelain aorta, aortic stenosis, aortic valve replacement

Sutureless Treatment for Blow-out Type Left Ventricular Free Wall Rupture

（Department of Cardiovascular Surgery, Kikuna Memorial Hospital, Yokohama, Japan）

Yutaka Narahara

Atsushi Bito

Noboru Murata

A 78-year-old woman who had had chest pain since 3 days previously, was given a diagnosis of acute myocardial infarction. Emergency coronary angiography revealed mid-left anterior descending artery and proximal right coronary artery lesions. Percutaneous coronary intervention was performed, and re-perfusion was successful. Cardiac tamponade was then diagnosed. Despite pericardial drainage, she remained in shock. After an intra-aortic balloon pump was established, an emergency operation was performed. On the operating table, her pulse disappeared. When thoracotomy was performed, a viscous hematoma was found in the pericardium. We found 3 ruptures in the left ventricular free wall, and hemorrhage. The diagnosis was a blow-out type left ventricular free wall rupture of the heart（LVFWR). We have used the patches-and-glue sutureless technique without cardiopulmonary support. This treatment for blow-type of LVFWR is rare.
  Jpn. J. Cardiovasc. Surg. 39:254-257（2010）

Keywords：left ventricular free wall rupture, blow-out type, sutureless technique

Ascending-to-Descending Aortic Bypass through a Median Sternotomy for Residual Coarctation of the Aorta

（Department of Cardiovascular Surgery, Tenri Yorozu Hospital, Tenri, Japan, and Department of Cardiovascular Surgery*, Kyoto, Japan）

Yuji Sekine	Tadashi Ikeda*	Tatsuya Furutake
Kenta Ann	Daisuke Nakatsuka	Michihito Nonaka
Atsushi Iwakura	Kazuo Yamanaka

A 11-year-old boy was admitted to our hospital with a diagnosis of the progressive residual coarctation of the aorta, severe left ventricular hypertrophy and dilatation of the ascending aorta. He had previously undergone 3 operations for coarctation of the aorta. We performed ascending-to-descending aortic bypass through a median sternotomy for residual coarctation of the aorta. Partial cardiopulmonary bypass（CPB）was established via the right femoral artery and right atrium. A cephalad retraction of the heart with a heart positioner and a longitudinal pericardial incision over the descending aorta allowed excellent exposure of the aorta through the posterior pericardium. The graft was anastomosed to the ascending aorta and descending aorta. The graft was brought around the right lateral aspect of the right atrium and through to the anterior aspect of right pulmonary veins and inferior vena cava. The bypass graft size was 14mm in diameter. The CPB time was 134 min, and operation time was 232 min. The postoperative course was uneventful, and he did not suffer from paraplegia. His blood pressure postoperatively normalized without medication. He was discharged 20 days after surgery. The ascending-descending aortic bypass through a posterior pericardium approach is a safe and effective option for relieving residual coarctation and improving hypertension, for patients who have complex coarctation requiring surgical correction. However, because of his young age（II）it is necessary to follow him up carefully.
  Jpn. J. Cardiovasc. Surg. 39:258-261（2010）

Keywords：residual aortic coarctation, median sternotomy, antianatomical bypass, ascending-to-descending aortic bypass, pericardial posterior approach

A Case of Acute Myocardial Infarction after Thrombolytic Therapy for Mechanical Valve Dysfunction in the Late Postoperative Phase

（Department of Cardiovascular Surgery, Aishinkai Ohsumikanoya Hospital, Kanoya, Japan）

Hideya Tanaka	Yoshihiro Nakayama	Hiroyuki Ohnishi
Junji Yunoki

The patient was a 65-year-old man who had undergone AVR（SJM Regent:19 mm）for AR in June 2007. Since March 2008 there had been an increase in the pressure gradient between the aorta and the left ventricle on transthoracic echocardiography（peak PG:46mmHg, mean PG:27 mmHg). Plain x-ray films of the valve showed limited opening of the metallic valve. However, no symptoms of heart failure were observed on a physical examination. Blood tests performed in December 2007 showed a PT-INR value of 1.22. Since the effects of warfarin anticoagulant therapy were insufficient, its dose was adjusted on follow-up. An examination in June revealed further stenosis of the valve（peak PG:93mmHg, mean PG:58 mmHg). Valve thrombosis was suspected because the condition was poorly controlled by warfarin. Thus, thrombolytic therapy using t-PA was performed（800,000 units). However, the patient complained of chest pain 1 h 30 min after initiation of thrombolytic therapy. Twelve-lead electrocardiography was performed, and ST-segment elevations were observed in the limb and chest leads. Acute myocardial infarction due to a free-floating thrombus was suspected, and emergency cardiac catheterization was performed. Segment 7 was totally occluded, and reperfusion was achieved by thrombus aspiration. Embolization of the coronary artery was speculated to have occurred because of the improved mobility of the metallic valve and dissolution of a thrombus adhering to the valve. A case of acute myocardial infarction as a complication of thrombolytic therapy for valve thrombosis is rare. This case reaffirms the necessity of careful monitoring during thrombolytic therapy.
  Jpn. J. Cardiovasc. Surg. 39:262-264（2010）

Keywords：prosthetic valve thrombosis, thrombolytic therapy

Ascending Aortic Replacement for Acute Type A Aortic Dissection in a Patient with Anti-phospholipid Antibody Syndrome

（Department of Cardiovascular Surgery, Takeda General Hospital Foundation, Aizuwakamatsu, Japan）

Takahiro Taguchi

Satoru Maeba

Keitaro Watanabe

Anti-phospholipid antibody syndrome（APLS）is characterized by the presence of anti-phospholipid antibodies, arterial or venous thrombosis, recurrent abortion, and thrombocytopenia. Although heart valve abnormalities are found in most patients with APLS, acute type A dissection associated with APLS is rare. A 44-year-old woman with systemic lupus erythematosus and APLS, who had been treated with corticosteroids, immunosuppressive agents, and warfarin, was admitted with severe back pain. Computed tomography demonstrated aortic dissection extending from the ascending to the abdominal aorta. Emergency ascending aorta replacement was performed. The hypercoagulation associated with APLS made it difficult to achieve optimal postoperative anticoagulant control. Moreover, corticosteroids and immunosuppressive agents may result in postoperative infection. However, this patient was discharged without complications 14 days after the operation.
  Jpn. J. Cardiovasc. Surg. 39:265-268（2010）

Keywords：anti-phospholipid antibody syndrome, acute aortic dissection, systemic lupus erythematosus

Leaflet Extension Aortic Valvuloplasty and Mitral Valve Replacement for Congenital Bicuspid Aortic Stenosis with Severe Mitral Regurgitation in a Child

（Depertment of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan）

Akito Imai	Yuji Hiramatsu	Shinya Kanemoto
Chiho Tokunaga	Muneaki Matsubara	Hideyuki Kato
Yoshie Kaneko	Yuzuru Sakakibara

A baby girl with a low birth weight was given a diagnosis of congenital bicuspid aortic stenosis and mitral valve prolapse. At the age of 40 days, she underwent balloon aortic valvotomy, but significant aortic regurgitation appeared afterwards. Another surgical intervention became necessary by the age of 20 months（weight, 5.7kg), because of intractable heart failure mostly caused by exacerbated mitral regurgitation. We performed a leaflet extension valvuloplasty for the small bicuspid aortic valve using an autologous pericardium treated by glutaraldehyde. The mitral valve was replaced with an ATS-16AP valve. Although her postoperative course was complicated with mitral paravalvular leakage and poor left ventricular function, she was discharged from hospital 6 months post operatevely. Leaflet extension valvuloplasty is a surgical option for infants with a small aortic annulus, but the procedure could be the only solution in cases when Konno or Ross techniques are not suitable.
  Jpn. Jpn. J. Cardiovasc. Surg. 39:269-272（2010）

Keywords：leaflet extension, congenital bicuspid aortic valve, small aortic annulus, infants

A Case of Late Acute Type A Aortic Dissection after Coronary Artery Bypass Grafting

（Department of Cardiovascular Surgery, Tottori Prefectural Central Hospital, Tottori, Japan）

Kengo Nishimura	Shigeto Miyasaka	Keisuke Morimoto
Iwao Taniguchi

Late acute type A aortic dissection after coronary artery bypass grafting（CABG）is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG（to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery）beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection（type A）on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.
  Jpn. J. Cardiovasc. Surg. 39:273-275（2010）

Keywords：acute type a aortic dissection, CABG, living graft, ascending artery replacement, redo cardiac surgery operation

A Case of Successful Hemostasis for Intraoperative Massive Endobronchial Hemorrhage after Mitral and Tricuspid Surgery

（Department of Cardiothoracic Surgery, Niigata Prefectural Shibata Hospital, Shibata, Japan）

Osamu Namura

Koji Shimada

Hajime Ohzeki

A 79-year-old woman with degenerative mitral regurgitation and secondary tricuspid regurgitation underwent mitral and tricuspid repair. Massive and intractable endobronchial hemorrhage occurred during weaning from cardiopulmonary bypass（CPB). Bronchoscopic examination during CPB revealed that the right distal bronchus was the probable bleeding point. We then performed a double-lumen endotracheal tube and a bronchial blocker in the distal portion of the right main bronchus. In addition, extracorporeal membrane oxygenation（ECMO）with a heparin-coating system was performed for 11 h, without extra heparinization because of severe hypoxia. The bronchial blocker was removed 14 h later, and the patient was weaned from ECMO 19 h after admission into ICU. Postoperative computed tomography（CT）revealed a pseudoaneurysm of the right pulmonary artery（A⁵b）corresponding with the probable site of bronchial bleeding（B⁵). We speculate that a pulmonary artery catheter induced this endobronchial hemorrhage. At 3 months after surgery the patient was doing well with no symptoms of airway bleeding, and her abnormal CT findings had disappeared.
  Jpn. J. Cardiovasc. Surg. 39:276-280（2010）

Keywords：endobronchial hemorrhage, cardiopulmonary bypass, pulmonary artery catheter, bronchial tamponade, ECMO

A Case of Patent Ductus Arteriosus with Infectious Endocarditis in Adult

（Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan）

Takamitsu Terasaki	Tamaki Takano	Toshihito Gomibuchi
Megumi Fuke	Kazunori Komatsu	Kohei Takahashi
Yuko Wada	Tatsuichiro Seto	Daisuke Fukui
Jun Amano

Infectious endocarditis（IE）concomitant with patent ductus arteriosus（PDA）is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography（CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39℃ and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.
  Jpn. J. Cardiovasc. Surg. 39:281-284（2010）

Keywords：patent ductus arteriosus, infectious endocarditis, bicuspid aortic valve