Japanese Journal of Cardiovascular Surgery Vol.40, No.6

Preface

• H. Makuuchi

Originals

• Evaluation of Coronary Artery Bypass Grafting with Multi-detector Computed Tomography and Coronary Angiography M. Kawasaki et al.…259
  Evaluation of Coronary Artery Bypass Grafting with Multi-detector Computed Tomography and Coronary Angiography

  （Department of Cardiovascular Surgery, Misato Central General Hospital, Misato, Japan, and Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Toho University*, Tokyo, Japan）

  Muneyasu Kawasaki	Katushi Niitsu	Msanori Hara*
  Yuki Sasaki*	Tomoyuki Katayanagi*	Nobuya Koyama*
  Yoshinori Watanabe*

  The evaluation of coronary arteries has become easier, with regard to postoperative coronary artery bypass grafting（CABG）evaluation through the development of multidetector computed tomography（MDCT). In this study, MDCT and coronary angiography（CAG）were performed for graft assessment after CABG, and the usefulness and assessment capability of MDCT were examined. We examined the morphology of graft stenosis and obstruction in 63 cases（51 men, 12 women, mean age 66 years old）in whom comparison by MDCT and CAG was possible. We used 49 grafts for LITA and 65 grafts for SVG（mean number of anastomoses 2.8). The graft evaluation was possible in all cases in CAG, but it was difficult to evaluate due to artifacts in 5 cases in MDCT. MDCT is less invasive than CAG and is useful for early postoperative assessment of CABG. Also, MDCT allows evaluation of the anastomotic region which can be difficult to evaluate from many directions in CAG, by building an image by the VR, MIP and MPR method. It was particularly useful for evaluation of the form of the whole graft and anastomotic region form by the curved MPR method. Further advance in the evaluation of coronary and bypass graft will depend on future developments in scaning methods and instrument improvements.
    Jpn. J. Cardiovasc. Surg. 40:259-264（2011）
  
  Keywords：CABG, MDCT, CAG
• Aortic Valve Replacement in Octogenarians:Are Concomitant Coronary Artery Bypass Grafting Operations Predictive Factors? Y. Fukumura et al.…265
  Aortic Valve Replacement in Octogenarians:Are Concomitant Coronary Artery Bypass Grafting Operations Predictive Factors?

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

  Yoshiaki Fukumura	Masahiro Osumi	Takashi Matsueda
  Atsushi Kurushima	Takashi Otani

  Because of increasing life expectancy and the high incidence of aortic stenosis（AS）in high-age groups, aortic valve replacement（AVR）for severe AS has become more frequent in recent years. The purpose of this study is to analyze operative outcome in octogenarians and evaluate the effect of concomitant coronary artery bypass grafting（CABG）for coronary artery disease. Between 2003 and 2010, 77 patients（18 men）aged over 80 years（80～88 years;mean age, 82.7 years）underwent AVR（bioprosthesis in 75 cases). Of these patients, 43.4% were categorized in New York Heart Association（NYHA）class III～IV and 41% had a history of congestive heart failure. In addition, 26 patients（33.8%）underwent associated CABG operations（1-4 grafts;mean, 1.8 grafts）with AVR. Operative mortality was 5.2%（4 patients). The operation time, cardiopulmonary bypass time, and aortic clamp time were significantly longer and amount of blood transfusion needed was greater in the concomitant CABG group than in the AVR-alone group. However, there were no differences between the groups with regard to intensive care unit（ICU）stay, postoperative hospital stay, operative mortality, and long-term survival. The outcome of AVR in octogenarians was good even in concomitant CABG patients. Aggressive surgical treatment of both aortic valve disease and concomitant coronary artery disease is warranted for most patients, despite advanced age.
    Jpn. J. Cardiovasc. Surg. 40:265-268（2011）
  
  Keywords：aortic stenosis, aortic valve replacement, octogenarians, CABG
• Finger Lifting Resternotomy Technique A. Yamauchi et al.…269
  Finger Lifting Resternotomy Technique

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

  Akihiko Yamauchi	Satoshi Muraki	Yasuko Miyaki
  Kazutoshi Tachibana	Mayuko Uehara	Masaki Tabuchi
  Tomohiro Nakajima	Yousuke Yanase	Nobuyuki Takagi
  Tetsuya Higami

  We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator’s finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.
    Jpn. J. Cardiovasc. Surg. 40:269-271（2011）
  
  Keywords：resternotomy, cardiovascular injury, hemorrhage
• Initial Results of Open Stent-Grafting Applied with a Matsui-Kitamura Stent in the Treatment of Thoracic Aortic Aneurysm H. Midorikawa et al.…272
  Initial Results of Open Stent-Grafting Applied with a Matsui-Kitamura Stent in the Treatment of Thoracic Aortic Aneurysm

  （Department of Cardiovascular Surgery, and Department of Pediatric Cardiovascular Surgery*, Southern Tohoku General Hospital, Koriyama, Japan）

  Hirofumi Midorikawa	Megumu Kanno	Takashi Takano
  Kouyu Watanabe	Kyohei Ueno	Shigehiro Morishima*
  Takashi Ono

  We reporte the initial results of open stent-grafting（OSG）applied with a Matsui-Kitamura（MK）stent in the treatment of thoracic aortic aneurysm（TAA). From August 2005 to March 2011, OSG for TAA was applied in 35 cases（male/female, 29/6, 58～86 years old, mean age 71). During deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, the stent graft was delivered through the transected proximal aortic arch, followed by arch replacement with a 4-branched prosthesis. Concomitant procedures included 1 coronary artery bypass graft, 1 mitral valve replacement and 2 pacemaker implantations. Operative mortality within 30days was 5.7%（respiratory failure in 1 and ischemic enteritis in 1). There was 1 in-hospital death due to brain stem infarction. Perioperative morbidity included 2（5.7%）stroke, 5（14.3%）spinal cord injuries（paraplegia in 1, paraparesis in 1 and transient paraparesis in 3）, and 1（2.9%）temporary hemodialysis. Ten patients（28.6%）were intubated for more than 72 h. There was no complication with the graft-related incident. These initial results suggested the OSG method applied with a MK stent is a useful surgical procedure for the treatment of TAA.
    Jpn. J. Cardiovasc. Surg. 40:272-278（2011）
  
  Keywords：open stent-graft, MK stent, thoracic aortic aneurysm（TAA), initial results

Case Reports

• A Case of Abdominal Aortic Aneurysm in Association with Congenital Factor XI Deficiency Y. Nishimura et al.…279
  A Case of Abdominal Aortic Aneurysm in Association with Congenital Factor XI Deficiency

  （Department of Cardiovascular Surgery, Mie Heart Center, Mie, Japan）

  Yoshiyuki Nishimura

  Toshiharu Ishii

  Yasuhide Ookawa

  Congenital factor XI deficiency is a rare intrinsic coagulation factor. We treated a 67-year-old man with abdominal aortic aneurysm, in whom activated partial thromboplastin time（APTT）found to be prolonged preoperatively. After fresh frozen plasma（FFP）was given before surgery, aneurysm was successfully replaced by a woven Dacron graft. No bleeding tendency was noted during the operation and FFP was also administered during and after surgery. The patient recovered without incident and left the hospital 13 days after the operation. Since several days are required to determine factor XI activity, APTT is useful as a parameter of coagulation factor activity in the perioperative period.
    Jpn. J. Cardiovasc. Surg. 40:279-281（2011）
  
  Keywords：congenital factor XI deficiency, abdominal aortic aneurysm, activated partial thromboplastin time（APTT）
• Mitral Valve Replacement for a Patient with Mirror-image Dextrocardia M. Hamamoto and D. Futagami…282
  Mitral Valve Replacement for a Patient with Mirror-image Dextrocardia

  （Department of Cardiovascular Surgery, JA Onomichi General Hospital, Onomichi, Japan）

  Masaki Hamamoto

  Daisuke Futagami

  Dextrocardia is a rarely seen cardiac malposition in which the heart is pointed toward the right side of the chest. A 77-year-old woman was admitted to our hospital with exacerbated exertional dyspnea. Cardiac examinations revealed severe mitral regurgitation due to prolapse of the posterior mitral leaflet in mirror-image dextrocardia（situs inversus, L-loop ventricles, and inverted great arteries). Mitral valve replacement using a bioprosthesis and pulmonary vein orifice isolation were successfully performed. The operative view of the surgeon standing on the left side of the patient showed mirror-image dextrocardia represents left-right reversal compared with normal heart structure. This provided some challenges in establishing cardiopulmonary bypass and performing intracardiac maneuvers. The mitral valve was on the left side of the surgeon and different needle grips, different angle of suturing, and the choice of forehand or backhand suturing were required to obtain secure suturing in the mirror-imaged mitral annulus.
    Jpn. J. Cardiovasc. Surg. 40:282-285（2011）
  
  Keywords：mirror-image dextrocardia, mitral valve replacement
• Apicoaortic Bypass with Coronary Artery Bypass Grafting for a Case of Severe Aortic Stenosis Y. Yanase et al.…286
  Apicoaortic Bypass with Coronary Artery Bypass Grafting for a Case of Severe Aortic Stenosis

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

  Yohsuke Yanase	Satoshi Muraki	Mayuko Uehara
  Kazutoshi Tachibana	Akihiko Yamauchi	Nobuyuki Takagi
  Tetsuya Higami

  We describe a 77-year-old woman with severe aortic stenosis, porcelain aorta and coronary artery disease, who underwent apicoaortic bypass with coronary artery bypass grafting. The patient, who had a history of aortitis syndrome had dyspnea. Cardiac echocardiography showed severe aortic valve stenosis（aortic valve pressure gradient（max/mean)＝115/74.4mmHg, aortic valve area＝0.48cm2). Coronary angiography showed severe stenosis of right coronary artery orifice（#1.90%）. Computed tomography showed severe calcification of the thoracic aorta and surgical manipulation for ascending aorta was impossible. We did not perform ordinary aortic valve replacement. Instead, apicoaortic bypass with coronary artery bypass grafting was performed. We approached by a left anterolateral thoracotomy at the 6th intercostal level. Apicoaortic valved conduit（valved graft:Edwards Prima Plus Stentless Porcine Bioprosthesis 19mm＋UBE woven graft 16mm）was implanted. Saphenous vein graft was harvested and coronary bypass grafting（valved conduit-#4AV）was performed in the same operative field. Postoperative cine MRI showed that most of the cardiac stroke volume flowed through the conduit（44.4ml/beat, 92.3%), with the flow via the aortic valve accounting for 3.69ml/beat, 7.7%. Postoperative enhanced CT showed that the coronary artery bypass graft was patent. Apicoaortic bypass is a good surgical option for aortic stenosis with severe calcification aorta and coronary artery bypass grafting can also be performed in the same view.
    Jpn. J. Cardiovasc. Surg. 40:286-289（2011）
  
  Keywords：porcelain aorta, aortic valve stenosis, angina pectoris
• Arteriomegaly with Multiple Aneurysms T. Yamagishi and K. Sakata…290
  Arteriomegaly with Multiple Aneurysms

  （Department of Cardiovascular Surgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan）

  Toshiharu Yamagishi

  Kazuhiro Sakata

  We report a rare case of surgical treatment of arteriomegaly with multiple aneurysms. The patient was a 76-year-old man who was suffering from swelling, pain, and numbness of his left lower extremity. Three-dimensional computed tomography（3D-CT）revealed arteriomegaly from the left external iliac artery to the popliteal artery with ruptured superior gluteal arterial aneurysm and superficial femoral aneurysm, and with unruptured external iliac aneurysm and popliteal aneurysm. We performed left external iliac artery―posterior tibial artery bypass, exclusion of superior gluteal aneurysm, and resection of three other aneurysms. Because of arteriomegaly, back flow from the dilated arterial branches was considerable, and the femoral artery was expanded with tension despite of distal and proxymal clamp. We therefore divided the femoral artery to avoid development of a aneurysm. The postoperative course was uneventful and 3D-CT showed good bypass flow and thrombotic occlusion of the residual femoral artery.
    Jpn. J. Cardiovasc. Surg. 40:290-293（2011）
  
  Keywords：arteriomegaly, popliteal arterial aneurysm, femoral arterial aneurysm
• Waffle Procedure Improved Hemodynamic Circulation of Constrictive Epicarditis T. Takano et al.…294
  Waffle Procedure Improved Hemodynamic Circulation of Constrictive Epicarditis

  （Cardiovascular Surgery, Ota General Hospital, Koriyama, Japan）

  Tomohiro Takano

  Koki Takahashi

  Masahiro Tanji

  A 62-year-old woman who had suffered from malignant articular rheumatism since 2000 felt fatigue, exertional dyspnea and edema was admitted in May 2009. Cardiac catheterization demonstrated a dip-and-plateau pattern of the pressure curve of RV. Therefore we diagnosed constrictive pericarditis. She decided to have surgery as soon as possible. As she had also been troubled with constrictive pulmonary damage, chronic renal failure, and was taking an inotropic agent, we concluded that the use of extracorporeal circulation was risky. After median sternotomy, we recognized diastolic insufficiency of the heart due to hypertrophy of the epicardium. Using an ultrasonic scalpel and electrotome, we incised the thickened epicardium with a waffle procedure. The dip-and-plateau disappeared and as a result the cardiac index was improved immediately（1.9l/min/m²→2.6l/min/m²). She was discharged on postoperative day 25. In this way waffle procedure for constrictive pericarditis can an effective surgical procedure for a high risk patient.
    Jpn. J. Cardiovasc. Surg. 40:294-297（2011）
  
  Keywords：constrictive pericarditis, pericardiectomy, waffle procedure
• Two Successful Reoperations for Ascending Aortic Pseudoaneurysm Long after Cardiovascular Surgery R. Arakaki et al.…298
  Two Successful Reoperations for Ascending Aortic Pseudoaneurysm Long after Cardiovascular Surgery

  （Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan）

  Ryoko Arakaki	Satoshi Yamashiro	Chisato Kamiya
  Tatsuya Maeda	Yuya Kise	Yuji Morishima
  Katsuya Arakaki	Yukio Kuniyoshi

  We describe two repeated operations to treat ascending aortic pseudoaneurysms. The first was emergency patch closure of the ascending aorta due to impending rupture 8 years after an operation for type I aortic dissection under hypothermic circulatory arrest. The second was endovascular repair using a fenestrated stent graft 7 years after coronary artery bypass grafting. No specific guidelines have been established regarding optimal management for such patients. We believe that individualized management is safer, especially for repeated operations.
    Jpn. J. Cardiovasc. Surg. 40:298-301（2011）
  
  Keywords：coronary artery bypass grafting, hypothermic circulatory arrest, pseudoaneurysm, endovascular aortic repair
• Early Postoperative Descending Aortic Rupture Following Ascending Aorta Replacement for Acute Type A Aortic Dissection N. Mouri et al.…302
  Early Postoperative Descending Aortic Rupture Following Ascending Aorta Replacement for Acute Type A Aortic Dissection

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

  Norio Mouri	Takeshi Shimamoto	Genichi Sakaguchi
  Tatsuhiko Komiya

  We report the findings in an 82-year-old man diagnosed with acute type A aortic dissection. Computed tomography scan showed that the primary entry site was located in the ascending aorta. This finding was confirmed intraoperatively, and emergency ascending aorta replacement of ascending aorta was performed. He subsequently died on postoperative 7 day due to descending aortic rupture. During autopsy, another entry site was found at the root of the brachiocephalic trunk with a patent false lumen, which might have led to the descending aortic rupture.
    Jpn. J. Cardiovasc. Surg. 40:302-305（2011）
  
  Keywords：acute type A dissection, descending aorta rupture, patent false lumen
• A Case of Acute Retrograde Aortic Dissection during TALENT Endovascular Repair of a Thoracic Aortic Aneurysm K. Sawada et al.…306
  A Case of Acute Retrograde Aortic Dissection during TALENT Endovascular Repair of a Thoracic Aortic Aneurysm

  （Department of Surgery, Kurume University, Kurume, Japan）

  Kentaro Sawada	Atsuhisa Tanaka	Seiji Onitsuka
  Keita Mikasa	Tomokazu Ohno	Satoru Tobinaga
  Teiji Okazaki	Shinichi Hiromatsu	Hidetoshi Akashi
  Shigeaki Aoyagi

  An 83-year-old woman underwent stent graft endovascular repair using a Medtronic TALENT device for a saccular aortic aneurysm in the distal arch. The landing zone which targeted the proximal side was directly distal to the orifice of the left common carotid artery（Z2), and the stent graft was placed at the targeted position. However, a decline in the right radial arterial pressure was observed immediately following this, and a retrograde dissected ascending aorta was observed on a transesophageal echocardiogram. The endovascular surgery was immediately converted to open surgery, and an intimal tear to the lesser curvature of the arch, caused by a bare spring（bare stent）of the proximal stent graft, was observed. Total arch replacement was performed by means of the concomitant use of the placed stent graft. Sometimes a TALENT stent graft exhibits specific movements（e.g. a misaligned opening）on its initial deployment. It is therefore believed that special attention is necessary when placing it in the aortic arch.
    Jpn. J. Cardiovasc. Surg. 40:306-309（2011）
  
  Keywords：thoracic aortic aneurysm, TEVAR, stent-graft, complications, aortic dissection
• Isolated Intracavitary Metastatic Esophageal Cancer of the Right Atrium and Right Ventricle I. Yamazaki et al.…310
  Isolated Intracavitary Metastatic Esophageal Cancer of the Right Atrium and Right Ventricle

  （Department of Cardiovascular Surgery, Fujisawa City Hospital, Fujisawa, Japan and Department of Surgery, Yokohama City University*, Yokohama, Japan）

  Ichiya Yamazaki	Hiromasa Yanagi	Motohiko Goda
  Shin-ichi Suzuki*	Munetaka Masuda*

  We report a rare case of isolated intracavitary metastatic esophageal cancer of the right atrium and ventricle. A 67-year old woman had been treated for esophageal carcinoma for three years. Combined radiotherapy and chemotherapy had been performed, and partial remission had been achieved. Recent follow up computed tomography of the chest revealed intracavitary cardiac mass in her right atrium and right ventricle. On echocardiography a mobile, irregularly shaped large mass was detected in her right atrium. She was admitted for emergency operation. We resected the mass under cardiopulmonary bypass. The pathological examination revealed intracavitary metastasis of squamous cell carcinoma of the esophagus. She was discharged on the 29th postoperative day. Six months later, she died from multiple metastases of squamous cell carcinoma. Even though the operation was not curative, it might have been effective for preventing tumor embolism to the lung and elongating life expectancy.
    Jpn. J. Cardiovasc. Surg. 40:310-313（2011）
  
  Keywords：cardiac metastasis, esophageal cancer, squamous cell carcinoma
• A Case of Abdominal Aortic Aneurysm Associated with Horseshoe Kidney S. Tomari et al.…314
  A Case of Abdominal Aortic Aneurysm Associated with Horseshoe Kidney

  （Department of Cardiovascular Surgery, Komaki City Hospital, Komaki, Japan, and Department of Vascular Surgery, Aichi Medical University Hospital*, Nagakute, Japan）

  Shiro Tomari	Masaru Sawazaki	Yoriko Kobayashi
  Naoto Izawa	Hiroyuki Ishibashi*

  Horseshoe kidney is a common renal anomalies, but coexistence with abdominal aortic aneurysm（AAA）is rare. Horseshoe kidney may cause various technical difficulties of aneurysm repair. A 76-year-old man was referred to our hospital for treatment of AAA with a horseshoe kidney. Preoperative 3-dimensional computed tomography（3D-CT）scans showed a pair of normal renal arteries and 3 accessory renal arteries from the anterior wall to abdominal aorta just proximal to an aneurysm. At operation, the aneurysm was exposed through a transperitoneal approach, and artificial graft replacement was performed with a woven Dacron bifurcated graft preserving the renal isthmus. The accessory renal arteries were not reconstructed. The postoperative course was uneventful. Postoperative 3-D CT showed minor infarction of renal isthmus, but renal function was not impaired.
    Jpn. J. Cardiovasc. Surg. 40:314-317（2011）
  
  Keywords：horseshoe kidney, abdominal aortic aneurysm, accessory renal artery
• A Successful Surgical Repair Tracheo-innominate Artery Fistula:TIF H. Watanabe et al.…318
  A Successful Surgical Repair Tracheo-innominate Artery Fistula:TIF

  （Department of Cardiovascular Surgery, Chiba Emergency Center, Chiba, Japan）

  Hiroyuki Watanabe	Shigeyasu Takeuchi	Mitsunori Okimoto
  Hisanori Fujita

  Tracheo-innominate fistula（TIF）is an uncommon life-threatening complication of tracheostomy. We report a 36 year-old man with post-tracheostomy TIF which was successfully repaired. After temporary control of bleeding, he was transported to our hospital by an ambulance helicopter. Emergency surgery was performed. The tracheal fistula was closed by direct suture and it was covered by sternocleidomastoid muscle flap. After sufficient irrigation, ascending aorta-innominate artery bypass was performed using 8mm Dacron graft through a right pleural cavity. The postoperative course was uneventful. The patient was discharged from our hospital after 30 days of operation. He has been in good condition for 3 years after surgery. Reconstruction of the innominate artery with vascular prosthesis is feasible even is cases of TIF. However, preventive measures are extremely important to avoid long-term complications such as graft infection or recurrence of TIF.
    Jpn. J. Cardiovasc. Surg. 40:318-321（2011）
  
  Keywords：tracheo-innominate artery fistula, surgical repair
• A Case of Emergency Surgery for a Huge Primary Right Atrial Angiosarcoma with Right Ventricular Failure and Shock Y. Kato et al.…322
  A Case of Emergency Surgery for a Huge Primary Right Atrial Angiosarcoma with Right Ventricular Failure and Shock

  （Department of Cardiovascular Surgery, Kameda Medical Center, Kamogawa, Japan）

  Yuji Kato	Masanori Kato	Mitsuhisa Kotani
  Kazuhiro Hisamoto	Yukiharu Sugimura	Masaaki Toyama

  We encountered a rare case of a 75-year-old woman who fell into right ventricular failure and shock with a comparatively rapid course due to a huge primary right atrial angiosarcoma occupying the right atrium. An emergency surgical excision of the tumor was performed and the right atrium was reconstructed with an EPTFE patch under cardiopulmonary bypass. On account of the positive margin, postoperative radiotherapy was added. There was no local recurrence, but adjuvant chemotherapy was performed for multiple lung and liver metastases 14 months after surgery. Primary cardiac angiosarcomas are extremely rare and have dismal prognoses. Although a complete surgical resection is the cornerstone of treatment, multidisciplinary therapy may improve patient outcomes.
    Jpn. J. Cardiovasc. Surg. 40:322-325（2011）
  
  Keywords：primary cardiac tumor, angiosarcoma, right heart failure
• Papillary Muscle Rupture of the Mitral Valve Caused by Traffic Accident H. Kuroki et al.…326
  Papillary Muscle Rupture of the Mitral Valve Caused by Traffic Accident

  （Department of Cardiovascular Surgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan, Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital*, Tsuchiura, Japan, and Department of Cardiovascular Surgery, Japanese Red Cross Musashino Hospital**, Musashino, Tokyo, Japan）

  Hidehito Kuroki*

  Noriyuki Tabuchi

  Tomoya Yoshizaki**

  A 59-year-old man was admitted to our hospital because of multiple traumas in a motorcycle accident. On admission, his vital signs were stable, however, 4 h later his respiratory condition suddenly worsened and be needed ventilatory support. Cardiogenic shock was suspected, however, the conventional echocardiograph findings were indistinct because of the presence of subcutaneous air. On the third day of hospitalization day, the Swan-Ganz catheter revealed high pulmonary arterial pressure. The subsequently performed trans-esophageal echocardiography showed severe mitral regurgitation. Therefore, semi-emergency mitral valve replacement was planned on the 5th hospital day. Operative findings showed that the anterolateral papillary muscle had torn off from the left ventricular wall and the associated strut chordae was also torn from the anterior leaflet. The post-operative course was uneventful, and the patient was discharged on the 40th postoperative day.
    Jpn. J. Cardiovasc. Surg. 40:326-329（2011）
  
  Keywords：traumatic mitral regurgitation, blunt chest trauma, heart injury, papillary muscle rupture, trans-esophageal echocardiography