|Atsushi Aoki||Tadashi Omoto||Kazuto Maruta|
（Department of Cardiovascular Surgery, Showa University, Tokyo, Japan）
Objective:The ascending aortic cannulation（Ao-C）is the routine procedure for cardiopulmonary bypass（CPB）in our hospital. However, for patients with diseased ascending aorta, such as severely calcified aorta, dissected or aneurysmal aorta, we used brachiocephalic artery（BCA）cannulation. The effectiveness and simplicity of BCA cannulation was evaluated. Methods:For patients with diseased ascending aorta, BCA was cannulated when the diameter of BCA is larger than 10 mm and is free from calcification, since January 2013. There were 62 patients who underwent aortic valve replacement（AVR）for aortic valve stenosis and BCA cannulation was applied for 11 patients. Standard Ao-C was used for remaining 51 patients. There were 44 patients with dissected or aneurysmal ascending aorta and BCA cannulation was applied for 7 patients, axillary artery perfusion was used for 15 patients and standard Ao-C was used for 22 patients. Consciousness level at the time of awaking from general anesthesia and any complication related with BCA cannulation was evaluated for the effectiveness. Simplicity was evaluated by the time required to establish CPB after skin incision. Results:In AVR patients, there was 1 patient with delayed consciousness level recovery with BCA cannulation and this patient was found to have cerebral infarction by CT. Intraoperative aortic dissection, probably due to BCA cannulation was observed in 1 patient, very old fragile and long period steroid user. In diseased ascending aorta patients, no patient suffered neurological accident nor any complication due to cannulation. In AVR patients, the time required to establish CPB after skin incision was 51＋/－9min in BCA cannulation and 47＋/－10min in Ao-C patients（p＝0.34). In diseased ascending aorta patients, the time required to establish CPB after skin incision was 49＋/－49min in BCA cannulation and 51＋/－16min（p＝0.82). Conclusion:BCA cannulation is a very simple and safe technique to establish CPB for patients with diseased ascending aorta. However great care should be taken, and BCA cannulation should be avoided for the long term steroid users or patients with connective tissue disease.
Jpn. J. Cardiovasc. Surg. 45:211-217（2016）
Keywords：brachiocephalic artery;cardiopulmonary bypass;severely calcified aorta;aortic dissection;ascending aortic aneurysm
|Koki Ito||Masaharu Hatakeyama||Shun-ichi Kawarai|
（Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital＊, Aomori, Japan）
Cor triatriatum is a rare congenital cardiac anomaly in which the accessory chamber is separated from the left atrium by an anomalous septum. We report a rare case of cor triatriatum with severe mitral regurgitation and atrial fibrillation in an adult. The patient was a 65-year old woman who developed congestive heart failure 3 years previously, and received medical follow-up with mitral regurgitation, atrial fibrillation and cor triatriatum since then. She developed congestive heart failure again and was referred to our hospital for operation for progressed mitral regurgitation, tricuspid regurgitation and atrial fibrillation. Mitral valve plasty（Physio ring II 28mm, cleft closure, edge to edge repair for PMC), tricuspid annuloplasty（Physio tricuspid ring 28mm), resection of the anomalous septum and maze procedure was performed. All of the pulmonary veins were connected to the accessory chamber. There was only one hole on the anomalous septum, and the hole was large, about 3.0cm in diameter. The patient regained sinus rhythm without mitral and tricuspid regurgitation after the operation. Even though the duration of atrial fibrillation was long and left atrium diameter was large, complete excision of the anomalous septum and maze procedure were effective for the patient diagnosed cor triatriatum.
Jpn. J. Cardiovasc. Surg. 45:218-222（2016）
Keywords：cor triatriatum;mitral regurgitation;tricuspid regurgitation;atrial fibrillation;maze procedure
|Makoto Hamaishi||Kenji Okada||Shinji Hirai|
（Department of Cardiovascular Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center＊, Kure, Japan, and Department of Cardiovascular and Respiratory Surgery, Hiroshima Prefectural Hospital＊＊, Hiroshima, Japan）
A 53-year-old man was urgently hospitalized with chronic renal failure, congestive heart failure, pulmonary edema, and pneumonia. He received respiratory support and dialysis after hospitalization in the intensive care unit. Coronary arteriography revealed an old myocardial infarction and unstable angina（triple vessel disease). Surgery was planned. However, after dialysis under heparin administration, clot formation was noted in the dialyzer. Serological tests confirmed the presence of antibodies to heparin-platelet factor 4 complex;accordingly, heparin-induced thrombocytopenia（HIT）was diagnosed. Coronary artery bypass surgery should preferably be performed early in the case of coronary artery disease. However, surgery during the acute phase of HIT when antibodies to heparin-platelet factor 4 complex（HIT antibodies）are present is associated with a very high risk of developing thromboembolism. There is no criterion regarding the optimal timing for surgery when HIT antibodies are present. Therefore, clinicians are often confused about this. In cases where the platelet count, D-dimer level, fibrinogen degradation product（FDP）level, and fibrinogen level improve, thrombin production due to HIT antibodies is thought to decrease. We considered that the improvement in these values suggests that the number of HIT antibodies decreases and thus HIT antibody activity would be reduced. We evaluated the platelet count, D-dimer level, FDP level, and fibrinogen level over time and accordingly determined the optimal timing for surgery. In the present case, argatroban administration was started after HIT developed, and the platelet counts increased gradually;the D-dimer and FDP levels decreased, whereas there were no significant changes in the fibrinogen levels. Although HIT antibodies were still present, we performed off-pump coronary artery bypass grafting under the administration of argatroban when the platelet count, D-dimer, and FDP values improved. The patency of coronary bypass grafts was confirmed postoperatively;the patient did not develop thromboembolism during the perioperative period and was discharged without complications. When HIT antibodies are present, an improvement in platelet count, D-dimer, and FDP values is thought to be useful in determining the optimal timing of surgery.
Jpn. J. Cardiovasc. Surg. 45:223-228（2016）
Keywords：heparin-induced thrombocytopenia;off-pump coronary artery bypass grafting;argatroban
|Kousuke Mori||Hirohito Ishii||Eisaku Nakamura|
|Joji Endo||Masanori Nishimura||Yukie Shirasaki|
（Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Japan）
A 64-year-old man originally underwent Bentall procedure for annulo-aortic ectasia for the first time at the age of 38 years. The surgery was to repair a pseudoaneurysm at the anastomotic site of the left coronary artery by direct closure 11 years after the first Bentall procedure. The anastomosis of the right coronary artery was normal at the time of the first reoperation. However, he had surgery to repair a pseudoaneurysm at the anastomotic site of the right coronary artery 26 years after the first operation;this was accomplished using the button technique. However, seven months after the second reoperation, he again manifested a pseudoaneurysm at the anastomotic site of the left coronary artery and died of rupture of the pseudoaneurysm. We report the case of pseudoaneurysms at the right and left coronary artery anastomoses that occurred three times after the first Bentall procedure.
Jpn. J. Cardiovasc. Surg. 45:229-232（2016）
|Takanobu Aoyama||Hiromichi Fujii||Hiroyuki Seo|
|Daisuke Kaku||Yoshikado Sasako|
（Department of Cardiovascular Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan）
A 41-year-old man had undergone mitral valve replacement（On-X 27/29mm）and tricuspid valve replacement（TVR）（On-X 31/33mm）for infectious endocarditis of the mitral valve and severe tricuspid regurgitation 6 years ago. Postoperative echocardiography showed aortic regurgitation and perivalvular leakage of the prosthetic mitral valve and left ventricular（LV）septal perforation. He therefore underwent aortic valve replacement（On-X 25mm), patch closure of a leak around the prosthetic mitral valve, direct closure of the LV septal perforation, and re-TVR（On-X 31/33mm). After discharge, he was placed on anticoagulant therapy with warfarin（international normalized ratio of prothrombin time target:2.0-2.5). Transthoracic echocardiography three and -a half years after the operation revealed an increased mean tricuspid valvular pressure gradient（14mmHg）compared with that seen on an echocardiograph of previous year. Cine-fluoroscopy showed almost no movement of the leaflets of the mechanical tricuspid valve. Tricuspid valve thrombosis or pannus formation was suspected. He was placed on thrombolytic therapy using tissue plasminogen activator（monteplase 1.6 million units). Five days later, cine-fluoroscopy showed movement of the mechanical tricuspid valve leaflets, and echocardiography revealed recovery of the mean tricuspid valve pressure gradient（4mmHg). Valvular thrombosis was diagnosed as the cause of the non-moving valve. Hemorrhagic and embolic complications were not observed. Thrombolytic therapy was extremely useful.
Jpn. J. Cardiovasc. Surg. 45:233-237（2016）
Keywords：mechanical prosthetic valve thrombosis;On-X valve;thrombolysis;t-PA
|Soichi Asano||Naoki Hayashida||Masanao Ohba|
|Kozo Matsuo||Hiroyuki Kito||Nobuyuki Hirose|
|Takuto Maruyama||Masashi Kabasawa||Hideomi Hasegawa|
（Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center＊, Ichihara, Japan）
We report a case of a 72-year-old woman, who had an anastomotic pseudoaneurysm in the ascending aorta, successfully treated by endovascular aortic repair with vascular embolic devise and stent-graft. It seemed to be high risk to achieve conventional surgery with extracorporeal circulation, therefore we selected endovascular treatment because she had a bleeding tendency which derived from disseminated intravascular coagulation. Then, we adopted stent-grafting with a vascular embolic device, because the distal side of pseudoaneurysm had too short a landing zone to cover the stent-graft only. The patient well tolerated this procedure and her postoperative course was uneventful. The pseudoaneurysm shrank at 6th months after operation.
Jpn. J. Cardiovasc. Surg. 45:238-241（2016）
Keywords：vascular embolic plug;TEVAR;ascending anastomotic pseudoaneurysm
|Yuki Yoshioka||Ryusuke Suzuki||Ryo Hirayama|
|Tomoya Miyamoto||Masaharu Mouri||Kenta Uekihara|
|Mai Matsukawa||Toshiaki Watanabe||Masamichi Nakajima|
（Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital＊, Kumamoto, Japan）
The case was a 27-year-old woman with a history of Turner syndrome. The patient underwent ascending-descending aorta bypass for aortic coarctation 6 years previously and underwent subsequent follow-up on an outpatient basis. She consulted our department because of fever, chest pain and headache as the main complaints. Age-indeterminate type A aortic dissection was found on computed tomography, and she was admitted to the hospital on the same day. Echocardiography also revealed an enlarged aortic root and bicuspid aortic valve. Aortic root replacement and total arch replacement were performed, and her postoperative course was favorable. It is reported that in cases of Turner syndrome with aortic coarctation, aortic aneurysm and aortic dissection are likely to occur due to the vulnerability of the aortic wall. We encountered a patient with Turner syndrome who underwent ascending-descending aorta bypass for adult aortic coarctation and subsequently developed type A aortic dissection, underwent aortic root and total arch replacement, and rehabilitated after surgery, as well as provide bibliographic considerations.
Jpn. J. Cardiovasc. Surg. 45:242-246（2016）
Keywords：Turner syndrome;adult aortic coarctation;bicuspid aortic valve;type A aortic dissection
|Hiroki Sato||Takeshi Okamoto||Kenji Aoki|
|Osamu Namura||Masanori Tsuchida|
（Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Science＊, Niigata, Japan）
A 55-year old man was admitted to our hospital owing to endograft collapse after TEVAR. He had undergone total arch replacement for acute aortic type A dissection at age 39, and undergone thoracic endovascular aortic repair（TEVAR）for chronic aortic type B dissection at age 54. TEVAR was successfully performed and the false lumen was shrunk. However, one year after TEVAR, computed tomography showed endograft collapse. Technical success was not achieved by the balloon technique to treat endograft collapse, so we performed additional TEVAR. After this procedure, endograft collapse was repaired. The postoperative course was uneventful.
Jpn. J. Cardiovasc. Surg. 45:247-250（2016）
Keywords：TEVAR;aortic dissection;endograft collapse
|Yoshimasa Oda||Hitoshi Oteki||Kozo Naito|
|Zyunichi Murayama||Toshihiro Fukui||Manabu Sato|
（Department of Thoracic and Cardiovascular Surgery, Saga Medical Centre Koseikan＊, Saga, Japan）
We report a rare case of a large thrombus in the ascending aorta with acute arterial occlusive disease. A 61-year-old man was transferred to our hospital with sudden pain and cyanosis. Contrast-enhanced computed tomography detected left ulnar arterial occlusion and a large mass in the ascending aorta, so we performed surgery to remove the large thrombus under cardiopulmonary bypass. Histologically, the mass was a fibrin thrombus. In addition, thickened endothelial lining and slight atheromatous degeneration was detected in the resected aortic wall. The patient was discharged from the hospital on postoperative day 22.
Jpn. J. Cardiovasc. Surg. 45:251-253（2016）
Keywords：aorta thrombus;acute arterial occlusive diseases;thrombectomy
|Muneaki Yamada||Yasuyuki Kato||Aya Takahashi|
|Daisuke Shiomi||Hiroshi Kiyama|
（Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital, Sayama, Japan）
A 45-year-old man was hospitalized with sudden-onset chest pain. He was in cardiogenic shock with a systolic pressure of 68mmHg. His electrocardiogram（ECG）showed ST segment elevation in leads I, aVL, and V2-5. An emergency coronary angiogram（CAG）showed that the true lumens of bilateral coronary arteries were compressed, showing acute Stanford type A aortic dissection involving bilateral coronary artery. A bare metal stent was promptly implanted in the left main trunk（LMT）to restore coronary blood flow because of his hemodynamic instability. Soon afterwards, the ischemic changes on ECG disappeared and he was transferred to the operating room in a stable hemodynamic condition. We performed emergency graft replacement of the ascending aorta and coronary artery bypass grafting. The postoperative CAG showed patent bypass grafts. Implantation of LMT stent, as a bridge to surgery, should be the treatment of choice for acute type A dissection involving LMT.
Jpn. J. Cardiovasc. Surg. 45:254-257（2016）
Keywords：type A acute aortic dissection;acute myocardial infarction;left main stenting