Japanese Journal of Cardiovascular Surgery Vol.40, No.2

Preface

• H. Shigematsu

Originals

• Early Clinical Results of On-Pump Beating-Heart versus Off-Pump Coronary Artery Bypass Grafting in Patients with Acute Coronary Syndrome T. Sugimoto et al.……43
  Early Clinical Results of On-Pump Beating-Heart versus Off-Pump Coronary Artery Bypass Grafting in Patients with Acute Coronary Syndrome

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

  Tsutomu Sugimoto	Kazuo Yamamoto	Koki Takizawa
  Takashi Wakabayashi	Hiroki Satoh	Satoshi Takahashi
  Shinpei Yoshii

  Emergency coronary artery bypass grafting（CABG）in patients with acute coronary syndrome（ACS）is still associated with high mortality and morbidity, and early outcome is poor compared with outcome in patients with stable angina. The purpose of this study was to examine the clinical results of on-pump beating heart CABG vs. off-pump coronary artery bypass（OPCAB）for ACS patients. From a total of 432 CABG patients, we retrospectively analyzed 72（16.7%）patients who underwent emergency CABG between 2004 and 2008. Emergency CABG cases were divided into 2 operative groups:an on-pump beating-heart CABG group（on, n＝31）and an OPCAB group（off, n＝41). A preoperative history of acute myocardial infarction（AMI), detection of troponin T, preoperative creatine phosphokinase（CPK）value, low ejection fraction, presence of mitral regurgitation（MR）（＞II）and cardiomegaly were markedly higher in the on group. There were no statistically significant differences in intraoperative factors. In-hospital mortality was 3.2%（1 patient）in the on group and 7.3%（3 patients）in the off group. Furthermore, statistically significant differences were found between the 2 groups in incidence of all-cause morbidity （on＝71.0%:off＝41.5%, p＝0.01), respiratory failure（on＝58.1%:off＝29.3%, p＝0.01), ICU stay（on＝6.5±4.6days:off＝4.1±3.2days, p＝0.01), and necessary inotropic support（on＝51.6%:off＝17.1%, p＝0.02). Multivariate regression analysis of preoperative and intraoperative factors was performed to identify independent factors for in-hospital mortality and morbidity. On multivariate analysis of preoperative factors, only the pre-CPK value reached statistical significance as an independent factor for in-hospital mortality and morbidity.
    Jpn. J. Cardiovasc. Surg. 40:43-47（2011）
  
  Keywords：acute coronary syndrome, emergency operation, on-pump beating CABG, OPCAB
• Effect of Edaravone on Cerebral Protection during Aortic Arch Surgery Y. Kitanaka et al.……48
  Effect of Edaravone on Cerebral Protection during Aortic Arch Surgery

  （Department of Cardiovascular Surgery, and Diagnostic Pathology Laboratory*, St. Marianna University School of Medicine, Kawasaki, Japan）

  Yousuke Kitanaka	Haruo Makuuchi	Hiroshi Murakami
  Makoto Ono	Takashi Ando	Kayoko Tanaka
  Shigeko Onuma*

  Edaravone is an agent developed as a free radical scavenger, and is useful in functional recovery of the brain after cerebral infarction. However, to the best of our knowledge no experimental studies have been made regarding the effect of edaravone on cerebral protection during aortic arch surgery. We investigated the pharmacological effect of edaravone experimentally, through selective cerebral perfusion under deep hypothermia. Twelve adult dogs（body weight 14.8±2.0kg）were used, and selective cerebral perfusion was performed under hypothermic circulatory arrest of 20°C for 120min at 5mg/kg/min, which was half the usual flow volume of cerebral perfusion. Group E（n＝6）received 3mg/kg edaravone for 30min at the start of both selective cerebral perfusion and rewarming of the body, while Group C（n＝6）received no drugs. Somatosensory evoked potential（SEP）was measured, and so were blood pressure, body temperature, pH level, oxygen partial pressure, and blood flow in the cerebral tissue. Histopathological investigations were also performed. In Group E, complete SEP recovery was observed in all dogs, while in Group C, complete SEP recovery was observed in only 2 dogs（33%）（p＝0.014). A statistically significant difference was also observed in cerebral tissue pressure（p＝0.014), but not in pH level, oxygen partial pressure, or cerebral tissue blood flow. On histopathological investigation, Group C demonstrated reduced staining of Nissl granules in neurons of the cerebral cortex, and many of them presented the appearance of acute circulatory impairment while Group E demonstrated no reduction in staining of Nissl granules. In the present experimental study of selective cerebral perfusion under deep hypothermia below the safety threshold flow, edaravone was effective in cerebral protection.
    Jpn. J. Cardiovasc. Surg. 40:48-53（2011）
  
  Keywords：Edaravone, aortic surgery, cerebral protection, selective cerebral perfusion

Case Reports

• Myocardial Angina due to Compression of the Left Coronary Artery by a Large Aneurysm in the Left Sinus of Valsalva A. Imai et al.……54
  Myocardial Angina due to Compression of the Left Coronary Artery by a Large Aneurysm in the Left Sinus of Valsalva

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

  Akito Imai	Kanji Matsuzaki	Tomohiro Imazuru
  Tomoaki Jikuya

  Sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of its origin among in the left sinus are scarce. This report describes a 38-year-old man with an isolated extracardiac unruptured aneurysm of the left sinus of Valsalva. The patient presented with chest pain due to compression of the main trunk of the left coronary artery by the aneurysm. The aneurysm was resected, and the aortic root was reconstructed using the Bentall procedure. Concomitantly, coronary artery bypass grafting（LITA-LAD）was added. Postoperative native coronary flow was fully restored, and his anginal symptoms disappeared despite occlusion of the additional LITA-LAD anastomosis. This type of case would be considered to not require concomitant CABG, since the cause of the coronary artery stricture was compression by an aneurysm in the left sinus of Valsalva.
    Jpn. J. Cardiovasc. Surg. 40:54-57（2011）
  
  Keywords：left sinus of Valsalva aneurysm, myocardial angina, bentall procedure, CABG
• Surgical Repair of Coronary Artery Fistulas with a Giant Coronary Artery Aneurysm Dilated from Valsalva Sinus N. Nishiki et al.……58
  Surgical Repair of Coronary Artery Fistulas with a Giant Coronary Artery Aneurysm Dilated from Valsalva Sinus

  （Kyoto First Red Cross Hospital, Kyoto, Japan）

  Nanae Nishiki	Akiyuki Takahashi	Masahiro Dohi
  Taiji Watanabe	Osamu Sakai	Masamichi Nakajima

  We report a case of a 64-year-old man who had a fistula from the right coronary artery to the right ventricle, with an asymptomatic giant coronary aneurysm. Multi-detector computer tomography showed an aneurysm from the sinus of Valsalva to the mid-right coronary artery（RCA). Its diameter was over 50mm. We performed aneurysmectomy direct closure of the fistula, and coronary artery bypass graft with saphenous vein graft cardiopulmonary bypass. The enlarged RCA orifice was closed with a vascular prosthesis, and the postoperative course was uneventful.
    Jpn. J. Cardiovasc. Surg. 40:58-61（2011）
  
  Keywords：coronary artery fistula, giant coronary artery aneurysm, sinus of Valsalva
• Trans-Thoracic Aortic Insertion of Intra-Aortic Balloon Pumping for the Patient of Ischemic Cardiomyopathy with Severe Arteriosclerotic Disease G. Kuwahara et al.……62
  Trans-Thoracic Aortic Insertion of Intra-Aortic Balloon Pumping for the Patient of Ischemic Cardiomyopathy with Severe Arteriosclerotic Disease

  （Department of Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka, Japan）

  Go Kuwahara	Tadashi Tashiro	Noritsugu Morishige
  Hidehiko Iwahashi	Masaru Nishimi	Yoshio Hayashida
  Kazuma Takeuchi	Noritoshi Minematsu	Nobuhisa Ito
  Yuta Sukehiro

  A 58-year-old man with diabetic nephropathy had been on hemodialysis for 15 years. He had lost his left leg below the knee and whole right leg due to atherosclerotic necrosis. During the past 3 years, his cardiac function had also gradually deteriorated. For the past 2 years, echocardiography showed progressively worsening mitral valve regurgitation. Coronary angiography showed severe stenosis in the left main trunk and left descending artery. Ischemic cardiomyopathy with mitral regurgitation were diagnosed. He underwent coronary artery bypass grafting and mitral valve annuloplasty. Because of difficulty in weaning him from cardiopulmonary bypass, he required intra-aortic balloon-pump (IABP) support. An IABP was inserted through the ascending aorta via a tube graft. It was removed on the 4th postoperative day with a small skin incision, under local anesthesia. The postoperative course was uneventful. This IABP insertion technique was useful for a patient with severe arteriosclerotic disease.
    Jpn. J. Cardiovasc. Surg. 40:62-65（2011）
  
  Keywords：trans-thoracic IABP, ASO
• Aorto-Right Ventricular Fistula and Vegetation in the Right Ventricle Associated with Infective Endocarditis after Aortic Valve Replacement H. Kumano et al.……66
  Aorto-Right Ventricular Fistula and Vegetation in the Right Ventricle Associated with Infective Endocarditis after Aortic Valve Replacement

  （Department of Cardiovascular Surgery, Northern Okinawa Cardiovascular Center, Nago, Japan）

  Hiroshi Kumano

  Keisuke Shuntoh

  Akimitsu Yamaguchi

  We report a rare case of aorto-right ventricular fistula and vegetation in the right ventricle after aortic valve replacement. A 74-year-old woman with a history of aortic valve replacement with a Carpentier-Edwards Perimount pericardial bioprosthesis 7 months earlier was admitted with fever. Methicillin-sensitive Staphylococcus aureus was detected from her blood culture. Transthoracic echocardiography showed an aorto-right ventricular fistula and vegetation in the right ventricle. Under a diagnosis of infective endocarditis, surgery was performed. The operative findings showed a fistula from the previous aortic suture line to the right ventricle, and substantial vegetation in the right ventricular outflow tract. No infective change was observed in the previously inserted prosthetic or pulmonary valves. The vegetation was removed and the fistula was closed directly with a single pledgeted 4-0 prolene mattress suture. The right ventricular outflow tract was reconstructed with a heterogeneous pericardial patch. The patient was discharged in good health on the 59th postoperative day without any infective complications.
    Jpn. J. Cardiovasc. Surg. 40:66-68（2011）
  
  Keywords：aorto-right ventricular fistula, infective endocarditis, aortic valve replacement
• Simultaneous Operation for Lung Cancer and Thoracic Aortic Aneurysm with Thoracic Endovascular Repair Y. Seto et al.……69
  Simultaneous Operation for Lung Cancer and Thoracic Aortic Aneurysm with Thoracic Endovascular Repair

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

  Yuki Seto	Hirono Satokawa	Yoichi Sato
  Shinya Takase	Hiroki Wakamatsu	Hiroyuki Kurosawa
  Eitoshi Tsuboi	Kenichi Muramatsu	Takashi Igarashi
  Hitoshi Yokoyama

  A 67-year-old man was given a diagnosis of lung cancer and thoracic aortic aneurysm（TAA). We first performed thoracic endovascular repair（TEVAR), and then right lower lobectomy for lung cancer. TEVAR shortened the operation time and yielded less operative damage. Therefore, TEVAR can be an effective choice for simultaneous surgery of TAA and lung cancer.
    Jpn. J. Cardiovasc. Surg. 40:69-71（2011）
  
  Keywords：thoracic aortic aneurysm, lung cancer, TEVAR
• A Case of Mitral Valve Plasty without Autologous Pericardium for Active Infective Endocarditis A. Shimizu et al.……72
  A Case of Mitral Valve Plasty without Autologous Pericardium for Active Infective Endocarditis

  （Department of Cardiovascular Surgery, and Department of Pathology*, Mitsubishi Kyoto Hospital, Kyoto, Japan）

  Atsushi Shimizu	Hiroyuki Nakajima	Hiroaki Osada
  Atsushi Nagasawa	Masahisa Kyogoku

  In recent treatment of mitral regurgitation due to active infective endocarditis, significant attempts have been made to repair as much of the mitral valve as possible. In cases where the leaflet is damaged extensively because of infection, valve repair generally becomes difficult unless the defect is reinforced by glutaric aldehyde-preserved autologous pericardium. We report a case in which mitral valve plasty for mitral regurgitation was performed under these circumstances. A 27-year-old man was admitted to our hospital because of headache and persistent fever. Transthoracic echocardiography revealed a 13-mm friable vegetation attached to the anterior leaflet of the mitral valve with severe mitral regurgitation. Urgent surgery was performed based on a diagnosis of active infective endocartitis. After cardiopulmonary bypass was performed and the aorta was cross-clamped, a left atriotomy was carried out on the interatrial groove. Much vegetation was attached to the damaged mitral leaflet from A3 to P3, and prolapse of the commissural leaflet was observed. The vegetation and damaged leaflet were then removed. Removal of the superficial vegetations enabled preservation of more than half of the A3. The valve was repaired by the resection-suture technique without using the autologous pericardium, as glutaric aldehyde solution was not available. Mitral annuloplasty using a 28-mm physio ring was performed thereafter. The postoperative course was uneventful and without any residual regurgitation. Nine months after surgery, no recurrence of infection or mitral regurgitation was not observed.
    Jpn. J. Cardiovasc. Surg. 40:72-76（2011）
  
  Keywords：infective endocarditis, mitral valve plasty, commisural leaflet disease
• Gallbladder Infarction Complication after Total Arch Replacement A. Shimizu et al.…77
  Gallbladder Infarction Complication after Total Arch Replacement

  （Department of Cardiovascular Surgery, and Department of Pathology*, Mitsubishi Kyoto Hospital, Kyoto, Japan）

  Atsushi Shimizu	Hiroyuki Nakajima	Hiroaki Osada
  Atsushi Nagasawa	Masahisa Kyogoku

  A 73-year-old man was referred to our hospital for treatment of a sacral aneurysm of the distal aortic arch with a maximum dimension of 66mm. He underwent total arch replacement（TAR）with cardiopulmonary bypass（CPB), moderate hypothermia, circulatory arrest（CA）of the lower body and antegrade selective cerebral perfusion（SCP）via a median sternotomy. Through the aneurysm, the descending aorta was divided and distal anastomosis was performed using the stepwise technique. After the inserted tube graft was extracted, a four-branched arch graft was anastomosed. The arch vessels and the proximal aorta were then anastomosed to the four-branched graft. The operation time was 515min, CPB time was 305min, aorta cross clamp（ACC）time was 213min, SCP time was 143min, and CA of the lower body was 97min. On postoperative day（POD）5, right-upper abdominal pain suddenly developed, with low grade fever. Acute cholecystitis was suspected and antibiotic therapy was started. On POD 6, his abdominal pain shifted to the lower-right region. His blood examination results were unchanged. Acute peritonitis was suggested by abdominal-enhanced computed tomography（CT), and emergency open cholecystectomy was then performed. There was no evidence of gall stones, and a bacterial culture of the ascites was negative. The pathological diagnosis was thromboendarteritis of the gallbladder artery, accompanied with thrombophlebitis and thrombosis, causing massive infarction at the neck of the gallbladder wall. His postoperative course was uneventful and he discharged in an ambulatory state on POD 16. In TAR, the risk of gastrointestinal ischemia is considerable because of prolonged circulatory arrest of the lower body and debris embolism. It is necessary to recognize possible gallbladder infarction, although it is rare, as a differential diagnosis of acute abdomen after TAR.
    Jpn. J. Cardiovasc. Surg. 40:77-80（2011）
  
  Keywords：gallbladder infarction, total arch replacement, circulatory arrest