Japanese Journal of Cardiovascular Surgery Vol.40, No.5

Preface

• K. Kawachi

Originals

• Tricuspid Valve Surgery for Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome J. Sugiura et al.……215
  Tricuspid Valve Surgery for Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome

  （Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan）

  Junya Sugiura	Hideaki Kado	Toshihide Nakano
  Kazuhiro Hinokiyama	Shinichiro Oda	Tomoki Ushijima
  Koki Eto	Hirohumi Onitsuka

  We reviewed our experience of tricuspid valve surgery for tricuspid regurgitation in hypoplastic left heart syndrome（HLHS）in terms of surgical timing, surgical procedures and long-term results. From May 1991 to July 2010, 105 classic HLHS patients underwent cardiac surgery, 28 of whom underwent a total of 31 tricuspid valve surgical procedures. Tricuspid valve surgery was performed in cases of moderate or more tricuspid regurgitation（TR). Type of the first tricuspid valve surgery was as follows:Annuloplasty in 15 patients, annuloplasty＋commissure closure in 7 patients, commissure closure in 2 patients, edge-to-edge repair in 2 patients, tricuspid valve replacement in 2 patients. Three patients underwent re-operation because of progression of TR. Two of them underwent tricuspid valve repair and one of them underwent tricuspid valve replacement. Follow-up was 60.1±53.0 months. Freedom from moderate or more TR after tricuspid valve surgery was 50.9% at 1 year, 42.0% at 3 years, 36.0% at 5 years. Among 17 patients who achieved total cavopulmonary connection procedure, 35.2% of patients had moderate or more TR, but central venous pressure（9.1±2.2mmHg), cardiac index（3.5±6.8 l/min/m2), arterial oxygen saturation（94.2±1.7%）showed as good hemodynamics after a Fontan procedure as non-tricuspid valve surgery cases. Appropriately timed aggressive tricuspid valve surgery yielded as good long-term results as HLHS without tricuspid valve surgery.
    Jpn. J. Cardiovasc. Surg. 40:215-220（2011）
  
  Keywords：hypoplastic left heart syndrome, tricuspid regurgitation, tricuspid valve surgery
• Treatment and Outcome of Acute Aortic Dissection Associated with Atherosclerotic Aortic Aneurysm H. Sakamoto et al.……221
  Treatment and Outcome of Acute Aortic Dissection Associated with Atherosclerotic Aortic Aneurysm

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

  Hiroaki Sakamoto

  Masataka Sato

  Yasunori Watanabe

  We set out to assess our treatment strategy of acute aortic dissection associated with atherosclerotic aortic aneurysm, and to assess its results. A total of 228 patients with acute aortic dissection were admitted to our hospital between 1994 and 2009. Among these, 30 cases were associated with atherosclerotic aortic aneurysm and we retrospectively analyzed their patient data. Of these, 5 patients received diagnoses of Stanford A dissection and 25 patients demonstrated Stanford B. Coexisting aneurysms consisted of postabdominal aortic replacement in 9 patients, ascending aortic aneurysm in 1, arch aortic aneurysm in 6, descending aortic aneurysm in 2, thoracoabdominal aortic aneurysm in 3, and abdominal aortic aneurysm in 9. Patients were divided into 3 groups based on the relationship between aneurysm and dissection:acute aortic dissection occurred after graft replacement of an aortic aneurysm（Group 1, n＝9), dissection coexisted with aneurysm in a different segment of the aorta（Group 2, n＝8), and dissection extended to or involved the aneurysm（Group 3, n＝13). Our treatment strategy for all patients excluding those with aortic rupture or malperfusion is described below. In the cases of Stanford A dissection, emergency ascending aortic replacement or total arch replacement was performed. In cases of Stanford B, patients were treated conservatively in the acute phase. Surgery for the coexisting aortic aneurysm was then performed in the chronic phase, if the aneurysm was large. We think that the interval between dissection onset and aneurysm surgery should be extended to at least 1 month, because the aortic wall was too fragile to perform anastomosis in the acute phase in the present cases. As a result, there were 2 hospital deaths in Group 3, but there was no aortic rupture during treatment in the acute phase in any of these 3 groups. There were no vascular-related deaths during follow up. Our treatment strategy obtained favorable outcomes.
    Jpn. J. Cardiovasc. Surg. 40:221-226（2011）
  
  Keywords：aortic dissection, thoracic aortic aneurysm, thoracoabdominal aortic aneurysm, abdominal aortic aneurysm
• Postoperative Atrial Fibrillation Following Off-pump Coronary Artery Bypass Grafting M. Shiraishi et al.……227
  Postoperative Atrial Fibrillation Following Off-pump Coronary Artery Bypass Grafting

  （Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical School, Saitama, Japan）

  Manabu Shiraishi	Atsushi Yamaguchi	Koichi Yuri
  Kazunari Nemoto	Kazuhiro Naito	Kenichiro Noguchi
  Hideo Adachi

  It has been demonstrated that atrial fibrillation（AF）frequently occurs after coronary artery bypass grafting（CABG）and may cause cerebral infarction. The purpose of this research is to clarify the risk factors of AF in patients who underwent off-pump CABG（OPCABG). In this study, 142 patients（111 men and 31 women）were enrolled with an average age of 67 years old（range, 33-83). According to multivariate analysis, age and the preoperative peak early (E)/late（A）diastolic velocities ratio（E/A）were the independent predictors of postoperative AF. Patients who suffered from postoperative AF required a significantly longer hospital stay.
    Jpn. J. Cardiovasc. Surg. 40:227-230（2011）
  
  Keywords：coronary artery bypass grafting, atrial fibrillation, off-pump CABG, risk factor

Case Reports

• A Surgical Case of Severe Aortic Valve Calcification Complicated by X-linked Hypophosphatemic Osteomalacia T. Igarashi et al.……231
  A Surgical Case of Severe Aortic Valve Calcification Complicated by X-linked Hypophosphatemic Osteomalacia

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

  Takashi Igarashi	Shinya Takase	Hirono Satokawa
  Hiroki Wakamatsu	Hiroyuki Kurosawa	Eitoshi Tsuboi
  Tomohiro Takano	Hitoshi Yokoyama

  A 34-year-old woman had received a diagnosis of X-linked hypophosphatemic osteomalacia when she was born. As an adult she complained of general fatigue, palpitations dyspnea exertional and leg edema. Transthoracic echocardiography showed aortic stenosis and regurgitation with severe aortic valve calcification. Chest computed tomography revealed her ascending aorta to be circumferentially calcified. Surgery was performed through a median sternotomy via cardiopulmonary bypass, with perfusion from the right subclavian artery and the right femoral artery and drainage from the superior and the inferior venae cavae. A left ventricular venting cannula was inserted from the right superior pulmonary vein. When her bladder temperature had dropped to 28℃ by central cooling, we stopped the perfusion from the right femoral artery and performed aortotomy. We examined the lumen and clamped the aorta at the usual site, while flushing with blood by femoral perfusion. Aortic valve calcification was observed to extend from the sinus of valsalva to the outflow tract of the left ventricle on the non-coronary cusp side. He was necessary to repair the aortic annulus due to a defect resulting from careful removal of the calcified valve. We then performed aortic valve replacement using a 19-mm Carpentier-Edwards perimount Magna. Her postoperative course was uneventful without any sign of neurological complications, and she was discharged 13 days after surgery. On pathological examination, localized ossification with calcification was observed in her aortic valve which seemed to be characteristic of X-linked hypophosphatemic osteomalacia.
    Jpn. J. Cardiovasc. Surg. 40:231-235（2011）
  
  Keywords：X-linked hypophosphatemic osteomalacia, aortic valve stenosis, aortic annulus calcification, ascending aorta calcification
• A Case of Emergency Ascending Aorta Replacement for Paraplegia Caused by Stanford Type A Acute Aortic Dissection R. Matsuura et al.……236
  A Case of Emergency Ascending Aorta Replacement for Paraplegia Caused by Stanford Type A Acute Aortic Dissection

  （Department of Cardiovascular Surgery, Social Insurance Kinan Hospital, Tanabe, Japan）

  Ryohei Matsuura	Nobuo Sakagoshi	Kenta Masada
  Yasuhisa Shimazaki

  We report a rare case of type A acute aortic dissection with paraplegia which was cured immediately after an emergency operation. A 79-year-old woman was transferred to our institution with sudden back pain and paraplegia. Computed tomographic scans revealed a cardiac tamponade with an acute type A aortic dissection. She went into shock soon after arrival, and about 4 hours from onset we performed an emergency replacement of the ascending aorta. Three hours after the operation, her neurological deficit gradually resolved and could walk by postoperative day 3. This case suggests that early restoration of the blood flow to the spinal cord is mandatory to relieve paraplegia caused by type A aortic dissection.
    Jpn. J. Cardiovasc. Surg. 40:236-239（2011）
  
  Keywords：type A acute aortic dissection, paraplegia, spinal ischemia, emergency operation, replacement of the ascending aorta
• Surgical Repair of an Aneurysm of the Right Aortic Arch with a Retroesophageal Aortic Segment and Mirror-image Branching S. Sawaki et al.……240
  Surgical Repair of an Aneurysm of the Right Aortic Arch with a Retroesophageal Aortic Segment and Mirror-image Branching

  （Department of Cardiovascular Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan）

  Sadanari Sawaki	Yuichi Hirate	Shinichi Ashida
  Akira Takanohashi	Kei Yagami	Masato Usui

  A 79-year old man presented with hoarseness and we diagnosed an aortic arch aneurysm, 60mm in diameter. The aortic arch was right-sided and traversed posterior to the esophagus and trachea, and the arch vessels were mirror-imaged. Total arch replacement was performed under hypothermic circulation arrest using selective cerebral perfusion through a median sternotomy. Three cervical vessels were reconstructed, a 24-mm Hemashield was passed anterior to the trachea and esophagus, and an additional right thoracotomy was not necessary. The patient was uneventfully discharged on the 26th postoperative day.
    Jpn. J. Cardiovasc. Surg. 40:240-243（2011）
  
  Keywords：right aortic arch, thoracic aortic aneurysm
• Surgical Treatment of a Caseous Calcification Lesion Which Originated from the Calcified Anterior Mitral Annulus in Patient on Chronic Hemodialysis T. Sassa et al.……244
  Surgical Treatment of a Caseous Calcification Lesion Which Originated from the Calcified Anterior Mitral Annulus in Patient on Chronic Hemodialysis

  （Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan）

  Toshiharu Sassa	Ryuji Kunitomo	Hisashi Sakaguchi
  Shuji Moriyama	Ken Okamoto	Mutsuo Tanaka
  Kentaro Takaji	Michio Kawasuji

  We report a case of a caseous calcification lesion originating from a calcified anterior mitral annulus. A 59-year-old woman on chronic hemodialysis was referred to our hospital due to an elevated brain natriuretic peptide value. Transthoracic echocardiography demonstrated moderate aortic valve stenosis with regurgitation and a pendulous mass in the left ventricular outflow tract, and therefore we perfomed. The patient underwent resection of the mass with aortic valve replacement. Pathological examination of the mass revealed interstitial calcium deposits but without tumors or inflammatory cells. We speculated that the cardiac mass was caseous calcification which originated from a severely calcified mitral annulus based on its echocardiographic and pathological features.
    Jpn. J. Cardiovasc. Surg. 40:244-246（2011）
  
  Keywords：mitral annular calcification, mass of the left ventricular outflow tract, hemodialysis
• Apicoaortic Conduit Bypass Surgery for Severe Calcific Aortic Valve Stenosis A. Yamashita et al.……247
  Apicoaortic Conduit Bypass Surgery for Severe Calcific Aortic Valve Stenosis

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

  Akitatsu Yamashita

  Akihiko Sasaki

  We report a case of a 79-year-old woman who underwent apicoaortic conduit bypass（ACB）surgery for severe calcific aortic valve stenosis. We did not perform conventional aortic valve replacement because of the patient’s advanced age and because she had a small aortic annulus（17mm）and a high risk of bleeding and cerebral infarction. ACB surgery through a left thoracotomy was performed via a femorofemoral bypass. A hand-made valve conduit was made from the left ventricular apex to the descending aorta. Her postoperative course was uneventful;postoperative echocardiography showed a decreased pressure gradient at the native aortic valve between the left ventricle and the aorta. This procedure is useful in high-risk patients with severe calcified aortic valve stenosis.
    Jpn. J. Cardiovasc. Surg. 40:247-250（2011）
  
  Keywords：apicoaortic conduit bypass, small aortic annulus, calcific aortic valve stenosis, stentless valve
• A Case of Aortic Valve Replacement Performed on a Beating Heart Y. Yokoyama et al.……251
  A Case of Aortic Valve Replacement Performed on a Beating Heart

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

  Yuichiro Yokoyama

  Harumitsu Satoh

  Masato Imura

  A 75-year-old man was admitted to our hospital because of severe aortic stenosis associated with fainting spells. He had undergone coronary artery bypass grafting at the age of 66, and had progressive aortic stenosis for 9 years. Ultrasound showed left ventricular hypertrophy and a calcified aortic valve. The aortic valve area was 0.34cm² and the mean pressure gradient was 56mmHg. Multi detector-row computed tomography showed patent bypass grafts（LITA-LAD, SVG-OM-PL, and SVG-RCA）and a persistent left superior vena cava（PLSVC). Coronary angiography revealed total occlusion of all the 3 native coronary arteries, therefore, antegrade cardioplegic perfusion was impossible. Retrograde perfusion was also impossible because of the PLSVC. We had to clamp the LITA and infuse the cardioplegic solution through the SVG graft to obtain cardioplegic arrest. Performing aortic valve replacement（AVR）on a beating heart facilitates the operation, because it negates the need to clamp the patent bypass graft and the PLSVC. We exposed a minimal area of the operating field, ascending aorta, and right atrium. Cardiopulmonary bypass was established by cannulating the ascending aorta and right atrium. The right pulmonary vein was cannulated for left ventricular venting. The ascending aorta was cross clamped on the proximal side of the SVG. AVR was thus performed using the standard approach on the beating heart with coronary perfusion through the bypassed graft. The postoperative course was uneventful, and the patient was discharged 15 days postoperatively. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. Beating heart surgery is one of the optional methods in such a complex case.
    Jpn. J. Cardiovasc. Surg. 40:251-254（2011）
  
  Keywords：beating heart surgery, aortic valve replacement, coronary artery bypass grafting
• A Case of Acute Renal Failure Following Abdominal Aortic Surgery M. Shiraishi et al.……255
  A Case of Acute Renal Failure Following Abdominal Aortic Surgery

  （Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan）

  Manabu Shiraishi	Atsushi Yamaguchi	Ken-ichirou Noguchi
  Hideo Adachi

  A 75-year-old man received a diagnosis of an abdominal aneurysm and underwent abdominal aortic replacement. His left internal iliac artery was sacrificed because of the difficulty of reconstruction. Rhabdomyolysis of the left gluteus muscle resulted in acute renal failure（ARF）postoperatively. Continuous hemodiafiltration（CHDF）was performed from postoperative day（POD）1 through POD 10 for the management of his ARF. During CHDF, the maximum value of serum creatinine was 5.10mg/dl and it returned to the normal range of 1.10mg/dl on POD 20. We conclude that the early deployment of CHDF was effective in rhabdomyolysis-induced ARF.
    Jpn. J. Cardiovasc. Surg. 40:255-258（2011）
  
  Keywords：rhabdomyolysis, abdominal aortic aneurysm, acute renal failure, hemodialysis