Japanese Journal of Cardiovascular Surgery Vol.40, No.4

Debranched Thoracic Endovascular Aortic Aneurysm Repair in a Case of Blunt Aortic Injury

（Department of Cardiovascular Surgery, Nagasaki University Hospital, Nagasaki, Japan）

Kazuki Hisatomi	Koji Hashizume	Tsuneo Ariyoshi
Shinichiro Taniguchi	Seiji Matsukuma	Ichiro Matsumaru
Daisuke Onohara	Mizuki Sumi	Kiyoyuki Eishi

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury（BAI）by contrast computed tomography（CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.
  Jpn. J. Cardiovasc. Surg. 40:159-163（2011）

Keywords：blunt aortic injury, thoracic endovascular aortic aneurysm repair, debranched, brain injury, multiple traumas

A Case of Transfusion-Related Acute Lung Injury after Total Arch Replacement for a Thoracic Aortic Aneurysm

（Department of Cardiovascular Surgery, and Divisions of Clinical Laboratory and Transfusion Medicine*, National Cerebral and Cardiovascular Center, Osaka, Japan）

Masatoshi Shimada	Hiroshi Tanaka	Hitoshi Matsuda
Hiroaki Sasaki	Yutaka Iba	Shigeki Miyata*
Hitoshi Ogino

An 84-year-old man with a thoracic aortic aneurysm underwent total arch replacement with selective antegrade cerebral perfusion. Immediately after the operation, respiratory distress and hypotension developed and Chest X-ray films and computed tomography showed bilateral lung edema. Echocardiography showed a small, underfilled left ventricle, but with preserved systolic function. We suspected transfusion-related acute lung injury（TRALI), and started sivelestat and steroid pulse therapy. His respiratory condition gradually improved, and he was discharged on postoperative day 78. The diagnosis of TRALI was confirmed by positive test results of an HLA class I antibody in the transfused fresh frozen plasma and T- and B-cells of the patient. TRALI should be considered as a cause of acute lung injury after surgery with blood transfusion.
  Jpn. J. Cardiovasc. Surg. 40:164-167（2011）

Keywords：cardiovascular surgery, blood transfusion, transfusion-related acute lung injury

A Case of Total Arch Replacement Using the Branched Graft Inversion Technique

（Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan, and Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University, Koshigaya Hospital*, Koshigaya, Japan）

Koyu Tanaka	Hidenori Yoshitaka	Yoshihito Irie*
Masahiko Kuinose	Toshinori Totsugawa	Yoshimasa Tsushima

Distal anastomosis during total arch replacement（TAR）for thoracic aortic aneurysm（TAA）is often difficult to perform because of the limited surgical view. The most common methods available are direct anastomosis of a 4-branched graft to the distal aorta, or stepwise anastomosis with the elephant trunk procedure. However, the stepwise technique requires graft-to-graft anastomosis, which is often associated with bleeding. In the present study, we developed a new approach, which we have termed the “Branched Graft Inversion technique”, which does not require anastomosis between grafts, and facilitates anastomosis with a view equal to that in the stepwise technique. A 65-year-old man with a diagnosis of saccular-type thoracic aortic aneurysm was admitted. Cardiopulmonary bypass was established by cannulating the ascending aorta and femoral artery via a median sternotomy. We performed distal anastomosis under selective cerebral perfusion during hypothermic circulatory arrest（25℃). An inverted branched graft was inserted into the descending aorta and anastomosed using mattress and running sutures together with outer reinforcement with a Teflon felt strip. The distal end of the inverted branched graft was then extracted, and reconstruction of the neck vessels and proximal anastomosis were performed. Our newly developed Branched Graft Inversion technique was useful during TAR for TAA.
  Jpn. J. Cardiovasc. Surg. 40:168-171（2011）

Keywords：Branched Graft Inversion technique, thoracic aortic aneurysm, total arch replacement, distal anastomosis

Two Cases of Unilateral Pulmonary Edema after Heart Surgery:Successful Strategy Using Veno-venous Extracorporeal Membrane Oxygenation

（Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Matsudo, Japan）

Hiromasa Nakamura	Hiroki Yamaguchi	Tatsuya Nakao
Yu Oshima	Noriyuki Tokunaga	Shinichi Mitsuyama
Koyu Watanabe

We report 2 patients with unilateral pulmonary edema after heart surgery who were successfully treated using venovenous extracorporeal membrane oxygenation（VV ECMO). Case 1:A 35-year-old woman presented with dyspnea. Echocardiography showed severe mitral regurgitation（MR）and tricuspid regurgitation（TR）and therefore, mitral valve plasty（MVP）and tricuspid annular plasty（TAP）were performed via right thoracotomy. After weaning from cardiopulmonary bypass, respiratory failure occurred with expectoration of foamy sputum and it was difficult to maintain oxygenation. Therefore, we performed VV ECMO to maintain oxygenation. A chest X-ray film after surgery showed ipsilateral pulmonary edema. After weaning from VV ECMO, deep venous thrombosis occurred and therefore we inserted an IVC filter. Case 2:A 67-year-old man, who had previously received aortic valve replacement experienced dyspnea and visited our hospital. Echocardiography showed an aortic root abscess, and therefore Bentall operation was performed. After weaning from cardiopulmonary bypass, oxygenation was difficult to maintain, and therefore we performed VV ECMO. A chest X-ray film post operatively showed right ipsilateral pulmonary edema. The patient was weaned from VV ECMO 5 days post operatively and was discharged 60 days post operatively. We believe that VV ECMO can be beneficial for patients with respiratory failure after heart surgery, but complications related to this approach such as DVT should also be considered.
  Jpn. J. Cardiovasc. Surg. 40:172-176（2011）

Keywords：unilateral pulmonary edema, VV ECMO

A Case of Aortic Root Replacement with a Left Main Trunk Patch Plasty

（Cardiovascular Center, Hokkaido Social Insurance Hospital, Sapporo, Japan, and Present address:Department of Cardiovascular Surgery, Hokkaido University Hospital*, Sapporo, Japan）

Toshihito Yoshida

Yuji Naito*

A 63-year-old woman with annuloaortic ectasia and severe aortic regurgitation was referred to our hospital. Preoperative coronary angiography revealed 50% stenosis of the orifice of the left main trunk. She underwent aortic root replacement, but we were unable to insert a 12-gauge cannula into the orifice of the left coronary artery because of cardioplegia. Therefore, we decided to perform patch plasty of the left main trunk by a saphenous vein patch. Her postoperative course was uneventful, and postoperative computed tomography（CT）showed good expansion of the left main trunk without any evidence of aneurysm formation.
  Jpn. J. Cardiovasc. Surg. 40:177-180（2011）

Keywords：left coronary artery orifice stenosis, patch plasty, annuloaortic ectasia, aortic root replacement

Hemolytic Anemia Associated with a Teflon Felt Strip on a Proximal Anastomotic Site for Aortic Replacement in a Patient with Aortic Dissection

（Department of Cardiovascular Surgery, Graduate School of Comprehensive Human Science, University of Tsukuba, Department of Cardiovascular Surgery, Toride Medical Association Hospital*, Toride, Japan, and Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital**, Tsukaba, Japan）

Chiho Tokunaga	Yoshiharu Enomoto	Shinya Kanemoto
Fujio Sato	Shonosuke Matsushita	Yuji Hiramatsu
Yutaka Watanabe*	Tomoaki Jikuya**	Yuzuru Sakakibara

A 61-year-old man was referred to our hospital for treatment of hemolytic anemia after ascending aortic replacement aortic dissection. Cine mode magnetic resonance imaging（MRI）showed stenosis at the proximal anastomostic site of a Teflon strip. We diagnosed hemolytic anemia induced by collision of red blood cells on the inverted felt strip. Conservative therapy with Sarpogrelate and β-blockers was effective to treat his hemolytic anemia. However, 7 years later he was re-admitted because of infective endocarditis at the aortic valve, and underwent aortic root replacement. Intraoperative findings showed a stiff and inverted Teflon felt strip causing stenosis of the proximal anastomosis. Hemolytic anemia should be considered a rare complication of using a Teflon felt strip to reinforce anastomosis for acute aortic dissection.
  Jpn. J. Cardiovasc. Surg. 40:181-183（2011）

Keywords：acute aortic dissection, Teflon felt strip, hemolytic anemia, Salpogrelate

A Case of Recurrent Rhabdomyosarcoma 11 Years after Radical Surgical Resection

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

Keisuke Watadani	Takeshi Shimamoto	Genichi Sakaguchi
Nobushige Tamura	Tatsuhiko Komiya

The prognosis of rhabdomyosarcoma is poor, and its estimated survival is less than year even after radical resection. We report a patient with recurrent rhabdomyosarcoma 11 years after obtaining remission by radical surgical resection and chemotherapy.
  Jpn. J. Cardiovasc. Surg. 40:184-187（2011）

Keywords：rhabdomyosarcoma, left atrium tumor, myxoma

Redo Cardiac Surgery after Previous CABG with Functioning Internal Thoracic Artery Grafts

（Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan, and Department of Cardiovascular Surgery, University of Miyazaki*, Miyazaki, Japan）

Kazushi Kojima	Eisaku Nakamura	Katsuhiko Niina
George Endo	Kunihide Nakamura*

We clinically reviewed 4 cases of redo cardiac surgery after previous CABG with functioning internal thoracic artery grafts. The patients consisted of 1 man and 3 women（76.8±8.3 years old). Internal thoracic artery（ITA）grafts were used in all patients. Furthermore, 2 mitral valve replacements, 1 aortic valve replacement and 1 replacement of the ascending aorta were performed as redo cardiac surgery. The heart was approached via a anterolateral right thoracotomy in 3 cases. Femoral artery cannulation was used for cardiopulmonary bypass, and the right superior pulmonary vein was exposed to vent the left ventricle in all patients. The functioning ITA grafts were not dissected and were clamped in all cases of the 4 patients, 2 underwent cardioplegic arrest under moderate hypothermia. We could not achieve cardioplegic arrest in 1 patient, and therefore we also performed deep hypothermic fibrillatory arrest. Another patient underwent deep hypothermic circulatory arrest. Serum CK-MB values were elevated in all cases（111.7±89.0IU/l ). However, these elevations did not correlate with intraoperative arrest duration or type of operative procedure performed. Operative mortality was 0%, and all patients were discharged with out any evidence of sequelae. Hypothermic fibrillatory arrest had an effective additional cardioprotective effect for incomplete cardioplegia in these 4 cases. Functioning ITA grafting was not necessary in dissection and clamping for cardioprotection. An anterolateral right thoracotomy provided a safe approach to the heart, avoiding functioning ITA graft injury.
  Jpn. J. Cardiovasc. Surg. 40:188-192（2011）

Keywords：redo surgery, cardioprotection, internal thoracic artery

Four Incidences of Recurrent Prosthetic Mitral Valve Detachment after DVR in a Single Patient Treated with Steroids

（Department of Cardiovascular Surgery, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan）

Akihito Sasaki	Kiyoharu Nakano	Kojirou Kodera
Ryouta Asano	Masahiro Ikeda	Go Kataoka
Satoru Doumoto	Wataru Tatsuishi	Sayaka Kubota

A 47-year-old man underwent a double-valve replacement involving aortic valve replacement（AVR）and mitral valve replacement（MVR）and Re-Re-DVR 6 and 8 months, respectively, after an initial DVR because of suspected prosthetic valve endocarditis. Detachment of the prosthetic mitral valve occurred during the early postoperative period, for which the patient again underwent treatment 15 and 21 months after the initial surgery. The operative findings showed that the detachment was caused by a wide cleavage of the aortic-mitral continuity. There were bacteria detected on a blood culture, and his C-reactive protein（CRP）level did not reduce at any time. On the basis of these findings, we suspected nonrheumatic inflammatory disease and started steroid therapy. His CRP level became negative, and further prosthetic mitral valve detachment did not recur.
  Jpn. J. Cardiovasc. Surg. 40:193-196（2011）

Keywords：prosthetic valve insufficiency, autoimmune disease, steroids, DVR

A Case of Swelling of Lower Extremity due to Iliac Vein Occlusion with IgG4-Related Idiopathic Retroperitoneal Fibrosis

（Department of Cardiovascular Surgery, Yodogawa Christian Hospital, Osaka, Japan）

Hideki Takahashi

Takashi Azami

A 62-year-old man presented with a chief complaint of swelling of the left lower extremity. Idiopathic retroperitoneal fibrosis had been diagnosed 6 years previously. Enhanced computed tomography demonstrated occlusion of the left common iliac vein, but without deep vein thrombosis, and a thick dense fibrous layer around the abdominal aorta and in front of the sacrum. After we administered steroid and anticoagulant therapy, remission of the swelling of the left lower extremity was obtained. Presently steroids are being gradually tapered, and he has remained free of recurrence of the swelling of his left lower extremity.
  Jpn. J. Cardiovasc. Surg. 40:197-201（2011）

Keywords：IgG4-related idiopathic retroperitoneal fibrosis, iliac vein occlusion, swelling of the lower extremity, steroid therapy, revascularization

A Case of Recurrent Metastatic Malignant Fibrous Histiocytoma in the Right Atrium Which Was Protruding into the Pericardial Space

（Department of Cardiovascular Surgery, Heart Center, Social Insurance Central General Hospital, Tokyo, Japan, and Department of Cardiovascular Surgery, Jichi Medical School*, Tochigi, Japan）

Akifusa Hariya	Kenji Takazawa	Koso Egi
Arata Muraoka*	Yoshio Misawa*

We report a rare case of a protruding tumor from the right atrial free wall into the cardiac sac. A cardiac tumor was incidentally detected in the right atrium of a 64-year-old man by transthoracic echocardiography. The tumor was located in the right atrial anterior free wall, infiltrating the right artrial appendage near the tricuspid valve annulus. It had an irregular surface, did not have a tumor stalk, and was considerably mobile. We resected the tumor and performed cryosurgical ablation of the remnant tissue to reduce the risk of local recurrence. Histopathologic examination confirmed the tumor to be metastatic malignant fibrous histiocytoma（MFH). The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Follow-up computed tomographic scans and transthoracic echocardiography did not reveal any evidence of local cardiac recurrence or distant metastasis.
  Jpn. Jpn. J. Cardiovasc. Surg. 40:202-205（2011）

Keywords：metastatic tumor of the right atrium, malignant fibrous histiocytoma, cryosurgical ablation

A Case of Surgical Resection of Malignant Lymphoma of the Duodenum with Right Atrial Invasion

（Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Seibu Hospital, Yokohama, Japan, and Present address:Department of Cardiovascular Surgery, St. Marianna University School of Medicine*, Kawasaki, Japan）

Kiyoshi Chiba*

Hiroyuki Abe

Yosuke Kitanaka*

We report a case of malignant lymphoma of the duodenum with right atrial invasion. A 71-year-old man presented with anemia and exertional dyspnea. Gastric fibroscopy showed a duodenal tumor pathologically diagnosed as diffuse large B-cell lymphoma（DLBCL). Echocardiography showed a large right atrial tumor. We performed urgent surgery to prevent a tumor embolism. As the tumor was firmly attached to the atrium, septum and ascending aorta, we performed partial resection to improve the patient’s hemodynamics status. Pathologic findings showed DLBCL. Systemic chemotherapy induced partial remission with out any cardiac recurrence.
  Jpn. J. Cardiovasc. Surg. 40:206-209（2011）

Keywords：diffuse large B-cell lymphoma, cardiac tumor with angina pectoris

Chronic Type B Aortic Dissection Associated with Disseminated Intravascular Coagulopathy:The Risk of a Patent False Lumen in the Chronic Phase

（Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan）

Masato Sakamoto

Manabu Hisahara

Patients with chronic type B aortic dissection usually require surgical repair due to aortic dissection-related complications, whereas those with uncomplicated type B acute aortic dissection can usually be managed with medical therapy. Disseminated intravascular coagulopathy（DIC), as well as aortic enlargement, visceral or limb ischemia and recurrent dissection, has been reported as one of the rare complications of type B aortic dissection which require surgical treatment in the chronic phase. DIC is a severe complication which can result in catastrophic events such as gastrointestinal and cerebral bleeding. The management of DIC as a complication of chronic aortic dissection is still controversial, as medical treatment involving anticoagulants and the supplementation of coagulation factors via a transfusion of fresh frozen plasma is not completely reliable. Surgical treatment to close a false lumen can be corrective, but carries the risk of excessive bleeding due to DIC. We report a patient with chronic type B dissection with a patent false lumen complicated by overt DIC. This patient had frequent occurrences of purpura on the upper and lower extremities. Contrast computed tomography in the late phase showed stagnation of contrast medium in the thoracic false lumen, which strongly idicated this false lumen to be the origin of the DIC. We gave the patient a continuous drip infusion of heparin（12,000U/day）for 1 week before the operation, after which we performed total aortic replacement in order to thrombose the false lumen. His coagulation profile, including platelet count, prothrombin time, international normalized ratio and clinical symptoms improved immediately after the operation. Computed tomography（CT）performed 3 months after the operation showed complete thrombosis and obstruction of the false lumen in the thoracic aorta. The patient is currently well and has resumed routine activities. The continuous infusion of heparin for 1 week was highly effective to improve the coagulopathy in the present case. This case underscores the importance of conducting follow-up to evaluate coagulation-fibrinolysis system function and to measure the aortic diameter by CT in patients with chronic type B aortic dissection with a patent false lumen. Comparison of the early and late phases of contrast-enhanced CT was extremely useful to determine the cause of coagulopathy in this case. Furthermore, the coagulopathy was successfully treated by total aortic arch replacement to close the entry of the false lumen.
  Jpn. J. Cardiovasc. Surg. 40:210-214（2011）

Keywords：chronic aortic dissection, DIC, coagulation-fibrinolysis system, coagulopathy, false lumen, anticoagulation therapy