|A Case of Vascular Graft Infection by Aspergillus Causing Distal Embolism to the Foot
A 77-year-old woman with previous aortic grafting for abdominal aortic and iliac artery aneurysms developed a blue toe in her left foot. Enhanced CT showed a high density area around the vascular graft of the left iliac artery, which partially protruded into the graft. Because of the elevated β-D glucan level, fungal infection of the vascular graft was strongly suspected. Her general condition precluded the graft removal. Instead, thrombectomy was performed. Microbial examination of the removed clot revealed infection by Aspergillus fumigatus. Voriconazole was administered for 3 months. The β-D glucan level was normalized. Only thrombectomy and Voriconazole administration can be an alternative in case with vascular graft infection by Aspergillus.
Jpn. J. Cardiovasc. Surg. 43:5-8（2014）
Keywords：Aspergillus;prosthetic graft infection;voriconazole
|A Case of Takotsubo Cardiomyopathy, Which Occurred after CABG and Was Complicated with Left Ventricular Outflow Tract Stenosis and Mitral Regurgitation
We report a case of Takotsubo cardiomyopathy that developed after elective coronary artery bypass grafting（CABG）in an 80-year-old woman. She had been given a diagnosis of unstable angina complicated with mild hypertrophic obstructive cardiomyopathy（HOCM). Her cardiac index began to fall 7h postoperatively, and we needed to infuse fluids and increase dopamine dose（up to 5μg/kg/min）to maintain cardiac index and blood pressure. CPK-MB level increased up to 140IU/l at 12h postoperatively. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base with accelerated left ventricular outflow tract（LVOT）flow and increased mitral regurgitation（MR). Emergency coronary artery angiography showed good patency of all bypass grafts and no new coronary lesion. We diagnosed Takotsubo cardiomyopathy. To improve the hemodynamic status, we started intra-aortic balloon pumping（IABP）instead of adding catecholamines. Blood pressure and cardiac index had improved temporarily, but became unstable again because of increased LVOT pressure gradient and moderate-to-severe MR. LV wall motion gradually improved, but the hemodynamic status stayed unstable, but improved after removal of IABP. In general, the prognosis of Takotsubo cardiomyopathy is favorable with supportive care. However, when it is associated with LVOT stenosis and significant MR, low cardiac output syndrome can become intractable, thus we should manage critical conditions with extreme caution.
Jpn. J. Cardiovasc. Surg. 43:9-14（2014）
Keywords：Takotsubo cardiomyopathy;hypertrophic obstructive cardiomyopathy;coronary artery bypass grafting;intra-aortic ballon pumping
|A Left Ventricular Pseudoaneurysm Related to Infective Endocarditis in the Mitral Valve
A 78-year-old woman who had undergone an axillobifemoral artery bypass with a prosthetic graft for Leriche syndrome presented 1 month later with cough and fever. A clinical examination revealed obvious redness in the right groin. Routine laboratory tests uncovered inflammation and methicillin-sensitive-Staphylococcus aureus was cultured from blood samples. Mitral valve vegetations were identified by echocardiography, and after a diagnosis of infective endocarditis, specific intravenous antibiotics were immediately administered. One month later, CT revealed a large pseudoaneurysm of the posterior left ventricular wall that had not been present at the time of admission. Transesophageal echocardiography and magnetic resonance imaging showed an aneurysmal cavity arising from the wall just below the posterior mitral valve leaflet. The patient agreed to undergo cardiac surgery due to the high likelihood that the pseudoaneurysm would rupture. The mitral annulus and leaflet were normal at surgery. We resected the posterior leaflet, closed the cavity using a Xenomedica patch, and reconstructed the leaflet. We did not remove the pseudoaneurysm using an extracardiac approach because the likelihood of damaging the coronary arteries and the coronary sinus was quite high. The postoperative course was uneventful. At follow-up 1 year later, the patient was afebrile and both CT and echocardiography showed that the cavity was completely filled by the thrombus. The imaging findings were useful in determining the surgical approach.
Jpn. J. Cardiovasc. Surg. 43:15-18（2014）
Keywords：infective endocarditis;pseudoaneurysm;xenomedica patch
|A Case of Tricuspid Valve Repair with Artificial Chordae after Resection of Tricuspid Valve Myxoma
Tricuspid valve myxoma is extremely rare. A 33-year-old woman who had undergone clipping of a cerebral aneurysm, had a cardiac tumor pointed out incidentally while undergoing echocardiography. Echocardiography showed a mobile and solid round mass（14×12mm）attached by a short stalk. We suspected a right ventricular tumor. Once the diagnosis of cardiac tumor has been established, prompt excision is essential to prevent complications, as well as syncope or collapse due to the transient occlusion of the tricuspid or pulmonary valves with embolization by the thrombus or fragments of the tumor tissue. Surgery was performed under cardiopulmonary bypass. The tumor was attached to the anterior papillary muscle and chordae of the tricuspid valve. The tumor was extirpated along with a piece of the papillary muscle and chordae. We performed tricuspid chordoplasty with artificial chordae. The histopathologic diagnosis was myxoma. The postoperative course was uneventful and the patient was discharged on the 15th day after the operation. While the patient has done well with no recurrence of the tumor during the five years that have passed since her operation, we will continue to observe her closely in the future because there have been some reports of recurrence after complete excision of cardiac myxoma and there are no long-term follow-up results of artificial chordae in the tricuspid position.
Jpn. J. Cardiovasc. Surg. 43:19-22（2014）
Keywords：tricuspid valve myxoma;artificial chorda;tricuspid valve repair
|A Case of an Aortic Pseudoaneurysm at the Site of Proximal Anastomosis Causing Hemolytic Anemia Postoperatively for an Ascending Aortic Replacement for Acute Aortic Dissection
A 55-year-old man was referred to our hospital for hemolytic anemia 21 months after an ascending aortic replacement for acute type A aortic dissection. The enhanced CT revealed an aortic pseudoaneurysm formation at the proximal anastomosis. The cause of hemolysis was verified to be the pressure by an aortic pseudoaneurysm formation at the vascular graft stenosis. At the reoperation, the previous vascular graft was found to have partially detached from the aortic stump over the non-coronary cusp. Ascending aortic replacement was performed with a tailoried vascular graft in a scallop shape, corresponding to the non-coronary cusp. The postoperative course was uneventful and hemolysis diminished soon after the operation.
Jpn. J. Cardiovasc. Surg. 43:23-26（2014）
Keywords：acute aortic dissection;pseudoaneurysm;hemolytic anemia
|A Case of Emergency Surgery for a Huge Primary Right Atrial Malignant Lymphoma with Right Ventricular Failure and Shock
We report a rare case of a 70-year old woman who suffered right ventricular failure and shock with a comparatively rapid course due to a huge primary right atrial malignant lymphoma occupying the right atrium. She had undergone mitral valve replacement and tricuspid valve annuloplasty due to combined valvular disease 12 years previously, and she had been treated for liver cirrhosis due to hepatitis C. The transthoracic echocardiography and the computed tomography scan revealed a huge tumor occupying the right atrial cavity and incarceration into the tricuspid valve ring. We performed an emergency operation to resect the heart tumor. As the tumor strongly adhered to the free wall of the right atrium and the tricuspid valve ring, we performed complete resection of the right atrial free wall and tricuspid valve. Therefore, we performed tricuspid valve replacement with a bioprosthesis, and reconstruction of the right free wall with an EPTFE sheet. The pathological examination of the tumor was consistent with malignant lymphoma of B-cell origin. These surgical procedures were effective to reduce acute right heart failure due to severe tricuspid valve regurgitation, but she died 3 months after surgery because of liver failure due to cirrhosis. Even though the operation was not curative, it might have been effective for preventing sudden death and acute right ventricular heart failure due to incarceration into the tricuspid valve ring of the huge right atrial tumor.
Jpn. J. Cardiovasc. Surg. 43:27-31（2014）
Keywords：primary cardiac malignant lymphoma;right heart failure;liver cirrhosis;incarceration into the tricuspid valve ring
|A Case of Repeated Acute Limb Ischemia with Malignant Tumor
A 72-year-old man had undergone aorto-bifemoral bypass for Leriche syndrome at age 67, but acute limb ischemia developed three times after the first operation, in January 2008, April 2008, and April 2009. There were no abnormal heart rhythms or thrombotic factors, and he had received anticoagulant therapy with warfarin（target prothrombin time-international normalized ratio:1.7 to 3.0）since January 2008. Nevertheless, he came to our hospital because of sudden onset of severe pain in the right lower limb in April 2010. Since CT showed occlusions in the right leg involving the aortobifemoral bypass and femoropopliteal bypass graft, emergency thrombectomy and femoropopliteal bypass（below knee), was performed. CT on admission showed enlargement of lymph nodes around the stomach, and gastric cancer was diagnosed by esophagogastroduodenoscopy. Since we considered the hypercoagulability in this patient with cancer to have resulted in repeated acute arterial thrombosis, these episodes were broadly diagnosed as Trousseau’s syndrome.
Jpn. J. Cardiovasc. Surg. 43:32-35（2014）
Keywords：Trousseau’s syndrome;malignant tumor;acute arterial thrombosis