Japanese Journal of Cardiovascular Surgery Vol.41, No.5

Preface

S. Kyo

Originals

Tricuspid Valve Surgery without Transplanting Transvenous Pacing Systems Y. Yokoyama and H. Satoh…219

Tricuspid Valve Surgery without Transplanting Transvenous Pacing Systems

（Department of Cardiovascular Surgery, Yotsuba Circulation Clinic, Matsuyama, Japan）
Yuichiro Yokoyama	Harumitsu Satoh

Transvenous pacemaker leads may impair tricuspid valve coaptation, and is a well-known cause of tricuspid regurgitation（TR). The mechanism underlying TR may be the perforation or laceration of the valve leaflets, direct lead interference with the valve closure, or adhesion of scar tissue between the leads of the pacemaker and the valve leaflet. Recently, three-dimensional echocardiography has clarified the pathway of the pacing lead and its interference with the tricuspid valve, but surgical treatment is not conventionally performed in the early stages of TR because of the necessity of the pacing lead. Occasionally, patients with TR develop severe right-sided heart failure, and the operative mortality in such conditions is very high. Thus, it is important to study the relationship between transvenous leads and TR. Tricuspid valve surgery is usually performed after replacing the transvenous lead with an epicardial lead. However removal of the transvenous lead may cause injury to the right ventricle, and ventricular chronic stimulation thresholds with epicardial stimulation have been shown to be significantly higher than those with endocardial stimulation. We performed TR surgery in 5 patients without removing the transvenous leads. To avoid interference with the valve closure, we shifted the pacemaker leads to the commissure and fixed them to the annulus. All the patients underwent successful tricuspid valve repair or replacement, and the symptoms of right-sided heart failure improved after the operation. We concluded that this technique is a very simple, and feasible method for treatment of most patients with TR caused by pacing leads.
Jpn. J. Cardiovasc. Surg. 41:219-223（2012）

Keywords：tricuspid valve regurgitation, pacemaker lead, lead fixation

The Mortality Following Coronary Artery Bypass Grafting in Patients with Dialysis-Dependent Renal Failure and the Risk Factor for the PrognosisS. Azuma et al.…224

The Mortality Following Coronary Artery Bypass Grafting in Patients with Dialysis-Dependent Renal Failure and the Risk Factor for the Prognosis

（Center for Cardiovascular Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Japan）
Shuhei Azuma	Shin-ichi Higashiue	Toshihiro Kawahira
Keiji Matsubayashi	Hisashi Tonda	Masatoshi Komooka
Norihiko Hiramatsu	On-ichi Furuya

There were 3,129 consecutive patients who underwent CABG by only one operator at Kishiwada Tokushukai Hospital between January 1991 and December 2010. These patients included 236 patients requiring chronic renal hemodialysis at the time of operation. They consisted of 181 men and 55 women, with an average age of 64.1±9.7 years. The mean duration of hemodialysis was 10.1±20.4 years. Diabetic nephropathy（133 cases, 56.4%）was the most common disease leading to required for hemodialysis. The operative mortality and the hospital mortality were 3.4% and 6.4% respectively. The 1-year survival rate, the 3-year survival rate, the 5 year survival rate and the 10-year survival rate were 72.4%, 48.3%, 32.4% and 14.3%. Multivariate logistic analysis revealed that only peripheral artery disease（PAD）was a significant risk factor for mortality（p＜0.05). The infectious diseases were the most common cause of long term death（24.1%). The mortality rates of CABG in patients with dialysis-dependent renal failure are still higher than those for non-hemodialysis patients. Our data suggest that PAD is a great risk factor for mortality following CABG in hemodialysis patients.
Jpn. J. Cardiovasc. Surg. 41:224-227（2012）

Keywords：chronic dialysis patient, coronary bypass operation, remote results, PAD

Case Reports

A Case of Acute Aortic Regurgitation due to Leaflet Dehiscence of a Carpentier-Edwards Pericardial Bioprosthesis 16 Years after Implantation M. Shingaki et al.…228

A Case of Acute Aortic Regurgitation due to Leaflet Dehiscence of a Carpentier-Edwards Pericardial Bioprosthesis 16 Years after Implantation

（Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan）
Masami Shingaki	Masaaki Koide	Yoshifumi Kunii
Kazumasa Watanabe	Kazumasa Tsuda

A 39-year-old woman, who had undergone aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis 16 years previously, was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. An emergency operation was undertaken with the patient in a state of shock due to sudden cardiac arrest. The ascending aorta was cross clamped, and cardiac arrest was induced, and aortotomy was done. One of the leaflets of the CEP was entirely collapsed and dislocated to the LV side, which caused acute aortic regurgitation. Although there was no evidence of endocarditis, slight calcification and small perforation of the leaflet of the valve was observed. Aortic valve replacement was performed with a mechanical heart valve but it was impossible to wean from ECC, and therefore we additionally performed mitral valve annuloplasty with a prosthetic ring for moderate mitral regurgitation. After 4 h cardiopulmonary assistance, ECC was successfully withdrawn. She was discharged in a good condition an post operative day 29th.
Jpn. J. Cardiovasc. Surg. 41:228-230（2012）

Keywords：acute aortic regurgitation, pericardial bioprosthesis, leaflet dehiscence

A Surgical Approach for Aortic Valve Replacement in a Patient with a Functional Right Internal Thoracic Artery Graft Located Close to the Posterior of the Sternum K. Furukawa et al.…231

A Surgical Approach for Aortic Valve Replacement in a Patient with a Functional Right Internal Thoracic Artery Graft Located Close to the Posterior of the Sternum

（Department of Cardiovascular Surgery, Miyazaki Medical Association Hospital, Miyazaki, Japan）
Kouji Furukawa	Takahiro Hayase	Mitsuhiro Yano

A 78-year-old woman who had undergone triple coronary bypass grafting with the right internal thoracic artery（RITA）to the left anterior descending artery 8 years previously was referred to our hospital because of heart failure due to progressive aortic valve stenosis. Coronary angiography showed that all of the coronary grafts were patent, and multidetector-row computed tomography demonstrated the functional RITA graft located close to the posterior of the sternum at the level of the second costal cartilage. To prevent injury of the RITA graft, we initially performed an inverted-L-shaped partial sternotomy extended to the right second intercostal space. After institution of peripheral cardiopulmonary bypass, we performed careful removal of adhesions along the posterior of the sternum under decompressed conditions and accomplished resternotomy safely. The patent internal thoracic artery grafts were never dissected and the patient was cooled to a rectal temperature of 22℃. After aortic crossclamping, myocardial arrest was obtained with systemic hyperkalemia by instilling 40 mEq of potassium chloride into the cardiopulmonary bypass circuit and we successfully performed aortic valve replacement. This method is an alternative approach for re-do cardiac surgery after previous bypass grafting in patients with a functional RITA graft located close to the posterior of the sternum.
Jpn. J. Cardiovasc. Surg. 41:231-234（2012）

Keywords：re-do cardiac surgery, aortic valve replacement, functional right internal thoracic artery graft, resternotomy, partial sternotomy

A Case of Ruptured Abdominal Aortic Aneurysm with Horseshoe Kidney H. Watanabe et al.…235

A Case of Ruptured Abdominal Aortic Aneurysm with Horseshoe Kidney

（Department of Cardiovascular Surgery, Chiba Emergency Medical Center, Chiba, Japan）
Hiroyuki Watanabe	Shigeyasu Takeuchi	Mitsunori Okimoto
Hisanori Fujita

Ruptured abdominal aortic aneurysm（AAA）associated with horseshoe kidney is an extremely rare condition. A 76-year-old man with lung cancer treated by radiotherapy was transfered to our hospital for emergency surgery of a ruptured AAA. Preoperative abdominal CT revealed an AAA 70mm in diameter, massive hematoma in the retroperitoneal space and horseshoe kidney with a huge renal cyst. Because the patient was in serious condition, we performed emergency operation immediately after arrival at our hospital. The AAA was replaced by a straight prosthtic graft without division of the renal isthmus, however one aberrant renal artery was sacrificed. The postoperative course was uneventful with no evidence of renal dysfunction. In cases of ruptured AAA in a state of shock, emergency operation is first priority. Even though we could do only minimal preoperative examinations, the surgery of the ruptured AAA with horseshoe kidney can be performed safely, if an accurate perioperative judgement for the treatment of abberant artery and renal isthmus is made.
Jpn. J. Cardiovasc. Surg. 41:235-237（2012）

Keywords：abdominal aortic aneurysm, rupture, horseshoe kidney

A Case of Early Progressive Aortic Valve Regurgitation after Coronary Artery Bypass Grafting in Aortitis Patient with Negative Findings for C-Reactive Protein and the Erythrocyte Sedimentation Rate K. Mukaihara et al.…238

A Case of Early Progressive Aortic Valve Regurgitation after Coronary Artery Bypass Grafting in Aortitis Patient with Negative Findings for C-Reactive Protein and the Erythrocyte Sedimentation Rate

（Department of Cardiovascular Surgery, Kagoshima Medical Center, Kagoshima, Japan）
Kosuke Mukaihara	Goichi Yotsumoto	Tomoyuki Matsuba
Kazuhisa Matsumoto	Takayuki Ueno	Yoshihiro Fukumoto
Hitoshi Toyohira	Masafumi Yamashita

We report the case of a 55-year-old woman with aortitis syndrome. She was admitted to our hospital because of repeated chest pain and syncope. An electrocardiogram and the laboratory data suggested acute myocardial infarction, and coronary angiography showed severe bilateral coronary ostial stenosis. No valvular disease was observed. Aortitis syndrome was suspected because of the stenosis of the brachiocephalic artery in addition to the bilateral coronary ostial stenosis, while the patient did not have elevated C-reactive protein（CRP）and erythrocyte sedimentation rate（ESR). Coronary artery bypass grafting was performed, and the patient’s postoperative course was uneventful. However, she again experienced chest pain 9 months after surgery due to aortic regurgitation（AR）and diffuse narrowing change of the left internal thoracic artery graft. Aortic valve replacement and Re-CABG was performed, and the patient was treated with steroid therapy postoperatively. The postoperative course was uneventful, but the patient thereafter died due to bleeding of a malignant adrenal tumor at 21 months after the second surgery.
Jpn. J. Cardiovasc. Surg. 41:238-242（2012）

Keywords：aortitis, aortic valve replacement, coronary artery bypass grafting, C-reactive protein, erythrocyte sedimentation rate

Pericardial Patch Closure Combined with Coronary Artery Bypass Grafting in a Case of Isolated Extracardiac Unruptured Left Sinus of Valsalva Aneurysm with Stenosis of the Main Trunk of the Left Coronary Artery N. Hatanaka and T. Ueda…243

（Department of Cardiovascular Surgery, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan）
Noriyuki Hatanaka	Takashi Ueda

A 76-year-old woman was admitted to our hospital because of sudden onset of chest pain and dyspnea. Echocardiography, chest CT, and cardiac catheterization revealed an isolated extracardiac unruptured left sinus of Valsalva aneurysm, with stenosis of the main trunk of the left coronary artery. Neither aortic regurgitation nor aortic annular dilatation was recognized. As an infection associated sinus of Valsalva aneurysm could not be ruled out, we performed patch closure using autologous pericardium and coronary artery bypass grafting to the left coronary system. The postoperative course was uneventful. One year after the operation, CT revealed that aneurysm of the left sinus of Valsalva had disappeared and that the grafts were patent.
Jpn. J. Cardiovasc. Surg. 41:243-246（2012）

Keywords：left sinus of Valsalva aneurysm, lesion of the LMT ostium, CABG

A New Technique for Composite Graft Preparation in Aortic Root Replacement Y. Sawada et al.…247

A New Technique for Composite Graft Preparation in Aortic Root Replacement

（Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Japan）
Yasuhiro Sawada	Shunsuke Sakamoto	Kazuya Fujinaga
Nin Tanaka	Toru Mizumoto

We report the Lampshade Technique:a new technique using Carbo-Seal Valsalva（Sorin Biomedica, Saluggia, Italy）to facilitate preparation of a composite graft. A Bentall operation and an ascending aorta replacement were performed with a composite graft using a Carbo-Seal Valsalva. This new technique can be considered useful as it can reduce the time required for preparing a composite graft, and create a skirt portion for continuous suturing to prevent bleeding.
Jpn. J. Cardiovasc. Surg. 41:247-249（2012）

Keywords：aortic root replacement, composite graft

Port-Access Minimally Invasive Cardiac Surgery for Patent Foramen Ovale Complicated with Paradoxical Cerebral Embolism T. Uchida et al.…250

Port-Access Minimally Invasive Cardiac Surgery for Patent Foramen Ovale Complicated with Paradoxical Cerebral Embolism

（Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan, and Cardiovascular Surgery, Iwaki Kyouritsu Hospital＊, Iwaki, Japan）
Tetsuro Uchida	Cholsu Kim	Yoshiyuki Maekawa
Eiichi Oba	Jun Hayashi	Yukihiro Yoshimura
Mitsuaki Sadahiro	Syunichi Kondo＊

The patient was a 63-year-old man, who had developed cerebral infarction during treatment for sleep apnea syndrome. He also presented typical features of deep venous thrombosis of the right lower extremity. Transesophageal echocardiography clearly showed the blood flow passing through the patent foramen ovale（PFO）followed by Valsalva maneuver. Paradoxical cerebral embolism caused by a PFO was diagnosed. Several procedures were considered to prevent recurrence of cerebral infarction, he underwent PFO closure by minimally invasive procedure, so-called port-access cardiac surgery. He started walking on the day of surgery, and postoperative echocardiography showed no residual shunt flow. Currently, no catheter-based PFO closure device is allowed in Japan, the PFO closure by the port-access technique should be considered as a feasible alternative.
Jpn. J. Cardiovasc. Surg. 41:250-252（2012）

Keywords：patent foramen ovale, paradoxical cerebral embolism, port-access surgery

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery with a Specific Left Coronary Artery Route Y. Ko et al.…253

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery with a Specific Left Coronary Artery Route

（Department of Cardiovascular Surgery, Saitama Children’s Medical Center, Saitama, Japan）
Yoshihiro Ko	Koji Nomura	Takayuki Abe
Toshiyuki Hoshina	Yuzuru Nakamura

We surgically treated a case of anomalous origin of the left coronary artery from the pulmonary artery with the specific route of the left coronary artery in a 17-month-old boy. He had suffered persistent cough and poor weight gain since the age of 4 months. An ultrasound cardiography, at the age of 16 months, revealed retrograde blood flow of the left coronary artery into the main pulmonary artery. Moreover, a chest computed tomography showed an anomalous left coronary artery arising from the bifurcation of the right pulmonary artery and winding in contact on the posterior aortic wall. Though the anomalous left coronary artery shared adventitia with the aortic wall we were able to separate the coronary artery from the aorta, and the patient underwent direct transplantation of the left coronary artery. The postoperative course was uneventful and recovery was rapid.
Jpn. J. Cardiovasc. Surg. 41:253-256（2012）

Keywords：anomalous aortic origin of left coronary artery, ALCAPA, coronary route abnormality, coronary wall adhesion

A Case of Coronary Artery Bypass Grafting for Anomalous Aortic Origin of a Coronary Artery T. Matsueda et al.…257

A Case of Coronary Artery Bypass Grafting for Anomalous Aortic Origin of a Coronary Artery

（Department of Cardiovascular Surgery, Japanese Red Cross, Tokushima Hospital, Komatsushima, Japan）
Takashi Matsueda	Masahiro Osumi	Motoki Tatsuo
Atsushi Kurushima	Takashi Otani	Yoshiaki Fukumura

Anomalous aortic origin of a coronary artery（AAOCA）can cause sudden death, especially in young athletes. AAOCA does not have any clinical cardiovascular manifestations and sudden death is often the first manifestation;hence, it is difficult to diagnose AAOCA before a major episode occurs. We report the case of a 58-year old woman with a right coronary artery arising from the left sinus and passing between the aorta and the pulmonary artery. Although the results of the exercise treadmill test and various other tests were normal, this patient underwent coronary artery bypass, surgery using the right internal thoracic artery to preventing sudden death. Two years after the operation, she is asymptomatic and has normal results on the exercise treadmill test.
Jpn. J. Cardiovasc. Surg. 41:257-261（2012）

Keywords：anomalous aortic origin of a coronary artery, sudden death, coronary artery bypass grafting

Aortic Valve Repair for an Aortic Valve Periprosthetic Leakage T. Fujii et al.…262

Aortic Valve Repair for an Aortic Valve Periprosthetic Leakage

（Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan）
Taishi Fujii	Tamaki Takano	Megumi Fuke
Kazunoki Komatsu	Kazuyoshi Otu	Takamitsu Terasaki
Yuko Wada	Daisuke Fukui	Jun Amano

A 77-year-old man underwent aortic valve replacement with a Carpentier-Edwards Pericardial Magna（19mm）for aortic stenosis. He presented with a low grade fever and congestive heart failure 6 months after the initial valve replacement. Staphylococcus aureus was detected in blood culture, and peri-valvular leakage was revealed by echocardiography. Prosthetic valve endocarditis was diagnosed and underwent re-aortic valve replacement with Medtronic Mosaic 21mm bioprothesis. Six months after the re-do operation, perivalvular leakage was newly observed between the right and non-coronary cusps, which was opposite to endocarditis affected cusps. The peri-valvular leakage was considered to have resulted from the fragile valve annulus because he did not have fever, and repeated blood culture showed no bacterial growth. We performed a third surgery and repaired the leakage by adding sutures through the right atrium and the interventricular septum to avoid directly suturing the fragile annulus. The post-operative course was uncomplicated, and no sign of endocarditis nor perivalvular leakage was observed during 9-months of observation. It is considered that the aortic valve fixation sutures through the right atrium and inter-ventricular septum are useful alternatives for fragile aortic annulus after prosthetic valve endocarditis.
Jpn. J. Cardiovasc. Surg. 41:262-265（2012）

Keywords：perivalvular leakage, repair, endocarditis

Abdominal Aortic Aneurysm with Right Ectopic Kidney H. Akashi et al.…266

Abdominal Aortic Aneurysm with Right Ectopic Kidney

（Department of Cardiovascular Surgery, Chiba Medical Center, Chiba, Japan, and Department of Cardiovascular Surgery, Chiba University Hospital＊, Chiba, Japan）
Hideyuki Akashi	Toru Ishizaka＊*	Hideo Tanaka*
Masahisa Masuda	Goro Matsumiya＊

We present the case of a 68-year-old woman with abdominal aortic aneurysm（AAA）complicated by right ectopic kidney, in another term, congenital pelvic kidney. The patient underwent AAA repair and right renal artery reconstruction using renal perfusion with cold Ringer’s acetate, and no deterioration of renal function was observed. 3D-CT was essential diagnostic procedure in order to identify the blood supply to the ectopic kidney for planning a careful surgical technique.
Jpn. J. Cardiovasc. Surg. 41:266-269（2012）

Keywords：abdominal aortic aneurysm, ectopic kidney, pelvic kidney

Endovascular Aneurysmal Repair for an Aortoenteric Fistula K. Eto et al.…270

Endovascular Aneurysmal Repair for an Aortoenteric Fistula

（Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan, Present address:Department of Metabolic Disorder, Research Institute, National Center for Global Health and Medicine＊, Tokyo, Japan）
Koki Eto＊	Hidenori Yoshitaka	Toshinori Totsugawa
Masahiko Kuinose	Yoshimasa Tsushima	Atsuhisa Ishida
Genta Chikazawa	Arudo Hiraoka

We report a case of secondary aortoenteric fistula（SAEF). A 76-year-old man who had undergone bifurcated graft replacement for an abdominal aortic aneurysm 18 years previously was admitted to our hospital on 2008. Since the patient was in hemorrhagic shock and had several comorbidities, he first underwent emergency endovascular aneurysmal repair（EVAR). The patient recovered from shock, and then the duodenal fistula was closed and a temporary tube enterostomy was made on the next day. The patient’s recovery was uneventful and he was discharged 34 days after EVAR without any sign of infection. However, the patient was admitted for a recurrent SAEF 16 months after the procedure. Although emergency surgery was performed, he died due to sepsis 11 days after surgery. EVAR could be useful to control bleeding associated with SAEF;however, it would be necessary for a long-term results to perform additional radical surgery subsequently to ensure the patients’ hemodynamic recovery.
Jpn. J. Cardiovasc. Surg. 41:270-275（2012）

Keywords：secondary aortoenteric fistula, endovascular aneurysmal repair, graft infection, pseudoaneurysm

Nail Gun Penetrating Injury of the Left Ventricle S. Mochizuki et al.…276

Nail Gun Penetrating Injury of the Left Ventricle

（Department of Cardiovascular Surgery, Tsuchiya General Hospital, Hiroshima, Japan）
Shingo Mochizuki	Shinichi Tsumaru	Kazunori Yamada
Takaaki Mochizuki	Toshihiko Ban

A 22-year-old man shot himself with a nail gun. He was admitted to a local hospital with chest pain. Chest x-ray film and chest computed tomography showed 5 nails penetrating the left thorax and some of these nails were considered to reach the pericardium. He was transferred to our hospital for intervention. Left thoracotomy was performed. Three nails reached the left ventricle and one nail was embedded the left lung. The last nail was found by transesophageal echocardiography to be completely buried in the left ventricle wall. All nails were removed and the left ventricular wounds were repaired with felt 4-0 surgipro mattress sutures. He made an uneventful postoperative recovery with a normal postoperative echocardiography and he was discharged on postoperative day 12 in good condition.
Jpn. J. Cardiovasc. Surg. 41:276-279（2012）

Keywords：penetrating cardiac injury, nail gun, cardiac tamponade, left thoracotomy

Acute Papillary Muscle Rupture due to Small Vessel Occlusion K. Tsuda et al.…280

Acute Papillary Muscle Rupture due to Small Vessel Occlusion

（Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan）
Kazumasa Tsuda	Masaaki Koide	Yoshifumi Kunii
Kazumasa Watanabe	Satoshi Miyairi

Papillary muscle rupture is one of the common complications of acute myocardial infarction. We report a case of 77-years-old man with an acute posterior papillary muscle rupture without obvious coronary artery disease. The patient presented with cardiogenic shock and pulmonary edema. Emergency coronary angiogram showed no obstruction in coronary arteries. An echocardiogram and right heart catheterization data suggested acute mitral regurgitation caused by ruptured posterior papillary muscle. Percutaneous cardiopulmonary support was induced because of his unstable hemodynamics, and then emergency mitral valve replacement was performed. Intraoperative findings suggested some ischemic changes in the posterior papillary muscle. Pathologically, both old and new ischemic lesion presented in the same papillary muscle. Moreover, severe thickening of a small vessel wall was noted. This case presented one of the possible mechanisms of so-called idiopathic papillary muscle rupture.
Jpn. J. Cardiovasc. Surg. 41:280-283（2012）

Keywords：papillary muscle rupture, mitral regurgitation, heart pathology