Japanese Journal of Cardiovascular Surgery Vol43,No4

Preface

• Developing Surgeon Scientist　T. Kitagawa

Originals

• Genomic Analysis for Preventing Complications due to Proton Pump Inhibitor and Warfarin Combination Therapy after Open-Heart Surgery H. Kimura et al.…163
  Genomic Analysis for Preventing Complications due to Proton Pump Inhibitor and Warfarin Combination Therapy after Open-Heart Surgery
  
  

  Haruka Kimura

  Mitsumasa Hata

  Motomi Shiono and Hisakuni Sekino

  
  

  （Division of Cardiovascular Surgery, Department of Surgery, Postgraduate School of Nihon University, Tokyo, Japan, and Sekino Hospital, Tokyo, Japan）

  Objective:Prevention of gastrointestinal bleeding is imperative in perioperative management of open-heart surgery. Although both proton pump inhibitors（PPIs）and Warfarin are often prescribed to patients following cardiac surgery, the US FDA warns that PPIs increase the international normalized ratio（INR）when used concomitantly with Warfarin, by being metabolized by cytochrome P-450（CYP）2C19. We assessed whether this drug interaction depends on the genotype of CYP2C19（Extensive Metabolizer, EM;Intermediate Metabolizer, IM;Poor Metabolizer, PM）or the type of PPI. Methods and Results:In this observational prospective study, the CYP2C9, CYP2C19, and VKORC1 genotypes of 78 patients were analyzed. After excluding cases with ＊1/＊3 of the CYP2C9 genotype and those with C/T of the VKORC1 genotype, 60 patients were assigned to Warfarin＋Rabeprazole（RB group, 30 cases）or Warfarin＋Lansoprazole（LP group, 30 cases). Warfarin was started with an initial dose of 3mg, and INR values were measured on days 4, 8, 14, 28, and 56. There was no significant difference in median Warfarin dose between the LP group（2.5mg/day）and RB group（3.0mg/day), （p＝0.88). The time in the therapeutic range（TTR）（Rosendaal）was significantly higher in the RB group（83.7%）than in the LP group（49.4%), and the time in the over range was significantly higher in the LP group（41.9%）than in the RB group（0.0%). In the LP group, TTR values were higher in CYP2C19 Extensive Metabolizers（EMs）than in Intermediate Metabolizers（IMs）and Poor Metabolizers（PMs), but there was no statistically significant difference between them. Conversely, in the RB group, there was no difference in the values of any CYP2C19 genotype. A multivariate analysis showed that high age and low TTR were risk factors for bleeding. Conclusion:We consider it possible that lower TTR values in the LP group were affected by the CYP2C19 genotype. In an aging society, Rabeprazole is safer and more effective as a proton pump inhibitor after open-heart surgery.　

   

  Jpn. J. Cardiovasc. Surg. 43:163-169（2014）

  Keywords：proton pump inhibitor;Warfarin;CYP2C19;drug interaction;bleeding complication after open-heart surgery

  
  
• Cardiovascular Surgery in Patients 85 or Older S. Gon et al.…170
  Cardiovascular Surgery in Patients 85 or Older
  
  

  Shigeyoshi Gon	Yasuyuki Yamada	Ikuko Shibasaki
  Toshiyuki Kuwata	Takayuki Hori	Go Tsuchiya
  Masahiro Seki	Yuriko Kiriya	Takashi Kato and Hirotsugu Fukuda

  
  

  （Dokkyo Medical University Hospital, Heart Center, Cardiac and Vascular Surgery, Tochigi, Japan）
  

  Background:This study was performed to evaluate surgical outcomes after cardiovascular surgery（including urgent surgery）in patients 85 or older. Methods:A retrospective analysis was performed on 39 patients（mean age, 86.3 years;age range, 85-90 years）who underwent total arch replacement（n＝4), ascending aorta replacement（n＝4), descending aorta replacement（n＝1), aortic valve replacement（AVR;n＝13), mitral valve replacement or valvuloplasty（n＝3), coronary artery bypass grafting（CABG;n＝9), CABG＋AVR（n＝4), tumor resection（n＝1）between June 2008 and December 2012 at Dokkyo Medical University Hospital. Results:Six hospital deaths occurred. One patient died due to bleeding from a ruptured descending thoracic aortic aneurysm, and another patient died due to gastrointestinal perforation from non-occlusive mesenteric ischemia（NOMI）after urgent AVR. The other deaths were related to various complications, including lung cancer, cholecystitis, myocardial infarction, and Takotsubo cardiomyopathy, during the postoperative period. Overall 30-day mortality was 2.6%, hospital mortality was 12.8%, duration of hospital stay after surgery was 41.3 days, duration of intensive care unit（ICU）stay was 3.8 days and ventilator time was 49.1 h. Twenty patients underwent elective surgery, and 19 patients underwent urgent surgery. The two groups had similar preoperative characteristics, except for the number of patients with aortic disease. No significant difference was evident in hospital mortality（26.3% vs. 5%, p＝0.065）or 30-day mortality（0% vs. 5.3%, p＝0.3）when comparing the two groups. However, the duration of hospital stay（58.9 days vs. 27.5 days, p＝0.049), ICU stay（6.74 days vs. 1.05 days, p＝0.002）and ventilator time（89.9 h vs. 8.2 h, p＝0.006）was significantly longer in the urgent surgery group than in the elective surgery group. Fourteen patients（70%）in the elective surgery group and four patients（21.1%）in the urgent surgery group were able to be discharged from the hospital to their homes within 30 days after surgery. These data demonstrated that cardiovascular surgery in patients 85 years of age or older was associated with satisfactory outcomes, and outcomes associated with elective surgery were even better than those associated with urgent surgery. Conclusions:Therefore, advanced age does not represent a contraindication of conventional cardiovascular surgery. Rather, the decision for surgery should take the patient’s preoperative condition, the severity of concurrent medical disease, the wishes of the patient, and the predicted functional outcomes into account.

   

  Jpn. J. Cardiovasc. Surg. 43:170-176（2014）

  Keywords：85 years old;elderly patient;cardiovascular surgery

  
  

Case Reports

• Aortic Regurgitation and Mitral Regurgitation in a Patient Concomitant with Coronary-to-Bronchial Artery Communication M. Sogawa et al.…177
  Aortic Regurgitation and Mitral Regurgitation in a Patient Concomitant with Coronary-to-Bronchial Artery Communication
  
  

  Masakazu Sogawa

  Takuya Fukuda and Hisanaga Moro

  
  

  （Division of Cardiovascular Surgery, Niigata Prefectural Central Hospital, Joetsu, Japan, and Division of Thoracic and Cardiovascular Surgery, Saiseikai Niigata Daini Hospital, Niigata, Japan）
  

  We report a rare case of combined valvular disease concomitant with the communication between the coronary and bronchial arteries. A 76-year-old woman was given a diagnosis of chronic heart failure 8 years previously and received medical therapy but recently she had dyspnea. Ultrasound cardiography revealed aortic regurgitation and mitral regurgitation. Cardiac catheterization confirmed the combined valvular disease and also revealed an aberrant coronary artery. Cardiac computed tomography showed coronary to bronchial artery communication, which caused myocardial ischemia. We performed aortic valve replacement with a bioprosthesis, mitral valve repair, and ligation and division of the aberrant coronary artery. Apart from some postoperative bronchial bleeding that ceased spontaneously the postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 43:177-180（2014）

  Keywords：coronary to bronchial artery communication;myocardial ischemia;combined valvular disease

  
  
• A Case of Graft Aneurysm due to Deterioration of a Cooley Double Velour Knitted Dacron Prosthesis S. Sakamoto and D. Sakamoto…181
  A Case of Graft Aneurysm due to Deterioration of a Cooley Double Velour Knitted Dacron Prosthesis
  
  

  Shigeru Sakamoto and Daisuke Sakamoto

  
  

  （Division of Cardiovascular Surgery Kanazawa Medical University, Himi Municipal Hospital, Himi, Japan）

  A 78-year-old man underwent replacement of a descending thoracic aorta in 1980 using a Cooley double velour knitted Dacron（CDVKD）following a diagnosis of DeBakey type III b aortic dissection. He had back pain and bloody sputum from around January 2012, and so the patient was referred to our department. Upon multi-detector computed tomography（MDCT), we diagnosed a graft aneurysm caused by the prosthetic graft carried out 32 years previously that had expanded to a maximum of greater than 80mm. An emergency operation was considered due to the continuing back pain and bloody sputum. As a strategy for treatment, low invasive treatment by thoracic endovascular aortic repair（TEVAR）was initially planned. However, due to the large size of the aneurysm relative to the surrounding vessels and severe aortic calcification of the landing zone, complications of endoleak and migration were considered possible upon TEVAR. Instead, we selected total aortic arch replacement with extracorporeal circulation upon median sternotomy, even though this required increased surgical invasion. Postoperative prognosis was good and the patient was discharged from hospital 5 weeks following surgery. There are few reports on the failure of a prosthetic graft causing a graft aneurysm, particularly involving an aging CDVKD graft, but it is possible that deterioration of a prosthetic graft may cause a graft aneurysm. Therefore, postoperative follow-up must be carried out with care.　

   

  Jpn. J. Cardiovasc. Surg. 43:181-184（2014）

  Keywords：graft aneurysm;cooley double velour knitted Dacron（CDVKD）;total arch replacement:redo operation

  
  
• A Case of Acute Thrombosis of Abdominal Aortic Aneurysm Y. Takesue et al.…185
  graft aneurysm;cooley double velour knitted Dacron（CDVKD）;total arch replacement:redo operation
  
  

  Yuki Takesue	Masahiko Matsumoto	Mitsuhiro Kimura
  Kentaro Kamiya	Masatake Katsu	Kenji Sakakibara
  Shigeaki Kaga and Shoji Suzuki

  
  

  （Department of Surgery II, Faculty of Medicine, University of Yamanashi, Chuo, Japan）
  

  An 80-year-old man felt a loss of strength and sharp pain in both lower limbs while playing gate-ball, consulted a nearby doctor, and was followed up. Because the sharp pains in both lower limbs became aggravated the next day, he was given a previously prescribed medication. Both femoral pulses were absent and acute arterial obstruction of the lower limbs was suspected. A contrast-enhanced CT scan showed a thrombosed infrarenal abdominal aortic aneurysm with a maximum transverse diameter of 37mm, and both external iliac arteries were contrast imaged by collateral circulation pathways. We diagnosed acute thrombosis of an abdominal aortic aneurysm, and was urgently transported to our hospital. We classified his lower limbs as Balas grade III and TASC classification grade IIb and Rutherford classification grade IIb. He exhibited no abdominal symptoms and since we confirmed the blood flow of his lower limbs, we decided to perform revascularization. An extra-anatomical bypass（axillo-bifemoral bypass）was conducted because he had dementia, and was old. After the operation, myonephropathic metabolic syndrome（MNMS）did not develop, and the patient was discharged on foot on the 16th postoperative day. Acute thrombosis of an abdominal aortic aneurysm is a rare disease. Because the ischemic area widens, often causing serious MNMS after the revascularization, it has a poor prognosis. Here, we report a case in which one such patient was rescued.
  

  Jpn. J. Cardiovasc. Surg. 43:185-190（2014）

  Keywords：acute thrombosis of abdominal aortic aneurysm;reperfusion injury;MNMS

  
  
• Incidental Diagnosis of a Giant Coronary Artery Pseudoaneurysm A. Hiromoto and J. Honda…191
  Incidental Diagnosis of a Giant Coronary Artery Pseudoaneurysm
  
  

  Atsushi Hiromoto and Jiro Honda

  
  

  （Department of Cardiovascular Surgery, Nakagami Hospital, Okinawa, Japan, and Present address:Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan）
  

  Coronary artery pseudoaneurysms are rare, and usually present as long-term complications of percutaneous coronary intervention or coronary artery bypass grafting, or as a side effect of systemic vasculitis, including Beh●et disease. A 60-year-old man was admitted to our hospital due to a hemorrhagic duodenal ulcer. As a mucosal bulge at the fornix was detected on upper gastrointestinal endoscopy, the patient underwent a further examination of other organs using computed tomography. Coronary computed tomography and coronary angiography revealed a right coronary artery aneurysm with a maximum diameter of 43mm and 90% stenosis in the left anterior descending artery. The patient successfully underwent coronary artery aneurysmectomy and coronary artery bypass grafting of the left anterior descending artery using the left mammary artery. The pathological findings were consistent with those of a pseudoaneurysm. In the present case, the coronary pseudoaneurysm may have been due to traumatic because he had experienced neither coronary treatments nor systemic vasculitis, although he had suffered blunt trauma that involved splenectomy 30 years earlier.

   

  Jpn. J. Cardiovasc. Surg. 43:191-194（2014）

  Keywords：coronary artery aneurysm;blunt trauma;pseudoaneurysm

  
  
• A Successful Surgical Treatment of Ebstein’s Anomaly by Hetzer’s Procedure in an Adult M. Nakao et al.…195
  A Successful Surgical Treatment of Ebstein’s Anomaly by Hetzer’s Procedure in an Adult
  
  

  Mitsutaka Nakao	Kiyozou Morita	Yoshihiro Ko
  Takayuki Abe and Kazuhiro Hashimoto

  
  

  （Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan）
  

  A 29-year-old woman, who had been diagnosed with Ebstein’s anomaly associated with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White（WPW）syndrome, was referred to our hospital for treatment of congestive heart failure and tachycardia. She had undergone a catheter ablation for WPW syndrome at the age of 28 years. Subsequently, surgical treatment for Ebstein’s anomaly was indicated because of persistent symptoms of heart failure due to tricuspid regurgitation（TR). The echocardiogram and pathologic findings corresponded to Ebstein’s anomaly of the Carpentier type B classification, with severe displacement of the septal and posterior leaflets resulting in moderate TR. A mobile anterior leaflet of sufficient size without a cleft enabled us to successfully perform Hetzer’s procedure. In this procedure, the large mobile anterior leaflet was approximated to the opposing true tricuspid annulus with a mattress suture of 3-0 polypropylene passed from the anterior leaflet annulus to the true tricuspid annulus at the site of atrialized right ventricle near the coronary sinus. The postoperative course was uneventful, and the cardiothoracic ratio reduced from 56% to 48% with mild TR. In this adult case of Carpentier’s type B adult Ebstein’s anomaly, Hetzer’s procedure allowed reconstruction of the tricuspid valve mechanism of “leaflet-to-septum” coaptation at the level of the true annulus by approximating the anterior leaflet. This was, effective in reducing the patient’s moderate TR. We conclude that this procedure is a simple and reproducible method for repairing the tricuspid valve in Ebstein’s anomaly, especially for cases with a large mobile anterior leaflet.　

   

  Jpn. J. Cardiovasc. Surg. 43:195-199（2014）

  Keywords：Ebstein’s anomaly;tricuspid valve plasty;Hetzer’s procedure;carpentier’s procedure

  
  
• Simultaneous Surgical Repair of Severe Pectus Excavatum Associated with Mitral Regurgitation, Angina Pectoris and Left Atrial Tumor for an Old Non-Marfan Patient A. Mihara et al.…200
  Simultaneous Surgical Repair of Severe Pectus Excavatum Associated with Mitral Regurgitation, Angina Pectoris and Left Atrial Tumor for an Old Non-Marfan Patient
  
  

  Akane Mihara

  Tomohiro Mizuno and Hirokuni Arai

  
  

  （Department of Cardiovascular Surgery, Machida Municipal Hospital, Tokyo, Japan, Present address:Department of Cardiovascular Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan, and Department of Cardiovascular Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan）
  

  Patients requiring simultaneous surgical repair for severe pectus excavatum and cardiac disease are rare, and most are children with congenital heart disease and chest deformity or young adults with Marfan syndrome. We experienced an old non-Marfan patient who had cardiac disease associated with severe pectus excavatum which needed thoracoplasty to approach the heart. A 69-year-old man with pectus excavatum was admitted because of dyspnea. We diagnosed acute congestive heart failure due to severe mitral regurgitation. A left atrial tumor and coronary artery disease were also diagnosed. Because of severe pectus, the heart was displaced to the left lower chest cavity. The distance between the sternum and the vertebrae was only 1cm. It was impossible to approach the heart without thoracoplasty. We simultaneously performed mitral valve replacement, 3-vessel coronary artery bypass grafting, resection of the left atrial tumor and thoracoplasty. His postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 43:200-204（2014）

  Keywords：pectus excavatum:mitral regurgitation;angina pectoris;Marfan syndrome

   

  
  
• Reoperation for Rupture of the Porcine Aortic Wall of a Stentless Bioprosthesis Y. Fukumura et al.…205
  Reoperation for Rupture of the Porcine Aortic Wall of a Stentless Bioprosthesis
  
  

  Yoshiaki Fukumura	Takashi Matsueda	Tatsuo Motoki
  Atsushi Kurushima and Takashi Otani

  
  

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

  A 63-year-old woman presented with pseudoaneurysm formation due to rupture of the porcine aortic wall of the stentless bioprosthesis. She had undergone aortic root replacement using the full root technique with the 25-mm Prima Plus bioprosthesis for annuloaortic ectasia. Congestive heart failure，appearing 65 months after the first surgery, progressed rapidly. Multidetector computed tomography（CT）showed a pseudoaneurysm of the aortic root, and echocardiography revealed severe mitral regurgitation. At reoperation, a large pseudoaneurysm with a 20-mm horizontal tear was seen in the non-coronary sinus of the Prima Plus valve. A repeat aortic root replacement and mitral valve replacement with two mechanical valves were performed. The patient had an uneventful recovery. Histologic examination of the explanted porcine aortic root showed host mononuclear cells and macrophages between the well-stained and poorly stained areas, suggesting that the torn tissue had undergone host-mediated degeneration to some extent. Porcine aortic roots have excellent hemodynamic features, but ruptures in the aortic sinuses of the porcine aortic root have been reported in some cases. Careful follow up with CT or echocardiography is therefore needed after aortic root replacement with stentless bioprostheses.

   

  Jpn. J. Cardiovasc. Surg. 43:205-208（2014）

  Keywords：Prima Plus stentless bioprosthesis;porcine aortic wall rupture;aortic root replacement;reoperation

  
  
• Left Atrial Undifferentiated Pleomorphic Sarcoma T. Itonaga et al.…209
  Left Atrial Undifferentiated Pleomorphic Sarcoma
  
  

  Tatsuya Itonaga	Masanao Nakai	Mitsuomi Shimamoto
  Fumio Yamazaki	Tatsuji Okada	Ryota Nomura
  Yasuhiko Terai	Yuta Miyano and Yusuke Murata

  
  

  （Department of Cardiovascular Surgery, Shizuoka Municipal Shizuoka Hospital, Shizuoka, Japan）
  

  We report a case of a 24-year-old woman who presented with orthopnea, in whom an echocardiographic exam showed a very large mass in the left atrium. We diagnosed this as cardiac failure due to the tumor occupying it. Although the tumor malignancy remained unclear, we had to perform emergency surgery to excise the tumor. The tumor was excised in its entirety, including the interatrial septum and a large segment of the left atrial wall. We reconstructed them with the autologous pericardium. The pathological diagnosis was undifferentiated pleomorphic sarcoma. Conventional adjuvant chemotherapy and radiotherapy was performed. Primary cardiac malignant tumor prognosis is very poor, but she has survived over 1 year without recurrent symptoms after complete excision and adjuvant therapy. In addition to reporting this case, we discussed the diagnosis and treatment of undifferentiated pleomorphic sarcoma.

   

  Jpn. J. Cardiovasc. Surg. 43:209-212（2014）

  Keywords：cardiac undifferentiated pleomorphic sarcoma;malignant fibrous histiocytoma;classification;diagnosis;therapy

  
  
• Re-expansion Pulmonary Edema after Mitral Valve Plasty via Small Right Thoracotomy N. Kanemitsu et al.…213
  Re-expansion Pulmonary Edema after Mitral Valve Plasty via Small Right Thoracotomy
  
  

  Naoki Kanemitsu	Kazuo Yamanaka	Takeshi Nishina
  Keiichi Hirose	Akihiro Mizuno	Daisuke Nakatsuka
  Yuki Hori	Daisuke Yasumizu and Masashi Yada

  
  

  （Department of Cardiovascular Surgery, Tenri Hospital, Tenri, Japan）
  

  We report a case of re-expansion pulmonary edema（REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support（PCPS）were introduced, and they were very effective. After five-days’ support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.

   

  Jpn. J. Cardiovasc. Surg. 43:213-217（2014）

  Keywords：minimally invasive cardiac surgery;re-expansion pulmonary edema;percutaneous cardiopulmonary support

  
  
• Endovascular Treatment of the Celiac Trunk for Ischemic Colitis in Two Cases Following Cardiac Surgery Y. Watanabe et al.…218
  Endovascular Treatment of the Celiac Trunk for Ischemic Colitis in Two Cases Following Cardiac Surgery
  
  

  Yoshiki Watanabe	Hiroshi Takano	Kei Horiguchi
  Masao Yoshitatsu	Kei Torikai	Seiichi Kawamoto
  Miho Yamakawa and Yusuke Iwasaki

  
  

  （Department of Cardiovascular Surgery, Department of Diagnostic Imaging, and Department of Cardiac Internal Medicine, Osaka General Medical Center, Osaka, Japan）
  
  

  Ischemic colitis following cardiac surgery is a rare but critical complication. We report two cases of ischemic colitis following cardiac surgery successfully treated with stenting of the stenotic celiac trunk. Case 1 was a 65-year-old man who developed perioperative myocardial infarction during off-pump coronary artery bypass grafting. He experienced abdominal pain and bloody stool on postoperative day 19. Severe ischemic changes in the sigmoid colon and descending colon were seen on colonoscopy, and CT scan revealed significant stenosis of the celiac trunk and occlusion of the inferior mesenteric artery and bilateral internal iliac arteries. Revascularization of the celiac trunk via stenting resulted in dramatic improvement in colonic ischemic changes. Case 2 was a 60-year-old woman who underwent a restoration procedure for a left ventricular aneurysm. She experienced gradual onset of postprandial pain beginning 9 days after surgery and massive bloody stool on postoperative day 33. Imaging revealed severe ischemic changes in the descending colon on colonoscopy and stenoses of the celiac trunk, superior mesenteric artery, inferior mesenteric artery, and bilateral common iliac arteries on CT angiogram. Stenting was performed to the celiac trunk on postoperative day 52. Her abdominal pain and bloody stool were completely resolved after treatment. Prior to the introduction of endovascular treatment of mesenteric ischemia in 1980, the standard treatment had been open surgical repair. Since then, endovascular repair has become widely accepted. In our experience, endovascular treatment of the mesenteric vessels may be an effective and less invasive approach to treating mesenteric ischemia in unstable patients after cardiac surgery.

   

  Jpn. J. Cardiovasc. Surg. 43:218-223（2014）

  Keywords：ischemic colitis;endovascular therapy;stenting;cardiac surgery;complications

  
  
• A Successfully Treated Surgical Case of Graft Duodenal and Colonic Fistula with Cardio-pulmonary Arrest after Abdominal Aortic Graft Replacement T. Ichihara et al.…224
  A Successfully Treated Surgical Case of Graft Duodenal and Colonic Fistula with Cardio- pulmonary Arrest after Abdominal Aortic Graft Replacement
  
  

  Toshihiko Ichihara

  Michio Sasaki and Tomonobu Abe

  
  

  （Department of Cardio-vascular Surgery, Tosei General Hospital, Seto, Japan, and Department of Cardiac Surgery, Nagoya University School of Medicine, Nagoya, Japan）
  

  A secondary aorto-enteric fistula can directly communicate with the gastroduodenal tract, colonic tract and the aorta in patients undergoing major surgery on the aorta, and this phenomenon is observed particularly often in patients who have undergone abdominal aortic graft replacement. We encountered a case of secondary aortoduodenal fistula and colonic fistula. The patient was a 60-year-old man who had previously undergone a graft replacement for an infra-renal abdominal aortic aneurysm. His present admission was due to episodes of gastro-intestinal hemorrhaging and he had also undergone an abdominal aortic graft replacement 2 months previously. The patient’s bleeding was managed conservatively. A scar was observed in the duodenum based on the endoscopic findings. At 10 days after admission, abdominal computed tomography（CT）showed active bleeding from the graft in the third portion of the duodenum. We therefore diagnosed secondary aorto-duodenal fistula. Since this pathogenic state may lead to serious massive gastroduodenal hemorrhaging, both an accurate diagnosis and emergency operation are therefore essential to successful treatment. We immediately inserted an intra-aortic occlusion balloon catheter（IABO). Thereafter, another aorto colonic fistula was detected after laparotomy, for the first time. First, the old graft was removed and the direct closure of the duodenum was performed, followed by omentopexy, colostomy, colostoma and then the extra-anatomical revascularization between the left axillary and bilateral femoral arteries was carried out. Finally, an intestinal feeding tube was inserted. The patient fell into a state of cardiac arrest during the operation due to the uncontrolled active bleeding in spite of the presence of IABO. An emergency thoracotomy was thus performed in the left 4th intercostal region. The descending aorta was clamped, and then all of the planned procedures were performed in order. The postoperative course was eventful, however, the patient’s lower thigh eventually had to be amputated due to ischemia of the clamped descending aorta. We encountered a case of graft duodenal and colonic fistula with cardio pulmonary arrest due to delayed diagnosis based on the endoscopic findings after abdominal aortic graft replacement. This case was successfully treated despite various difficulties in making a timely and accurate diagnosis.

   

  Jpn. J. Cardiovasc. Surg. 43:224-229（2014）

  Keywords：post replacement of abdominal aortic aneurysm;prosthetic graft duodenal fistula;prosthetic graft colonic fistula;cardio pulmonary arrest

  
  
• Clamshell Thoracotomy for Two Cases of Blunt Traumatic Cardiac Rupture T. Miki…230
  Clamshell Thoracotomy for Two Cases of Blunt Traumatic Cardiac Rupture
  
  

  Takahisa Miki

  
  

  （Critical Care Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan）
  

  When a sufficient field of view in unilateral thoracotomy cannot be obtained during hemostasis surgery for severe thoracic trauma, clamshell thoracotomy is often necessary to perform aortic cross-clamping in order to avoid cardiac arrest or to treat intrathoracic injury across the chest. Here we describe two successful cases of clamshell thoracotomy for blunt traumatic cardiac rupture. Case 1 was a 41-year-old male motorcyclist, injured in a collision with a truck, who was in a state of shock when transported to our emergency department（ED). Due to the finding of fluid accumulation around the spleen on FAST（focused assessment with sonography for trauma), he underwent emergency laparotomy with gauze packing after splenectomy as damage control surgery. Because of a prolonged state of shock due to extensive right hemothorax, right anterolateral thoracotomy was performed to locate the site of active bleeding in the right mediastinal pleura. However, imminent cardiac arrest necessitated clamshell thoracotomy, which revealed a 4-cm laceration on the right atrium and two lacerations on the upper lobe of the right lung, for which suture repair was performed. His postoperative course was uneventful and he was discharged on postinjury day 57 for rehabilitation. Case 2 was a 75-year-old female motorcyclist who was injured after hitting a curb and falling. She was in a state of shock due to severe right hemothorax when admitted to our ED and underwent anterolateral thoracotomy to treat active bleeding in the right mediastinal pleura. Clamshell thoracotomy was performed because cardiac arrest was imminent, and this was followed by suture repair of a 2-cm laceration identified on the left atrium. Her postoperative course was uneventful and she was transferred to another hospital on postinjury day 37 for rehabilitation. In both cases, Clamshell thoracotomy was performed successfully for blunt traumatic cardiac rupture and the postoperative course was good with no serious complications. Clamshell thoracotomy is an effective approach for trauma resuscitation, so surgeons should be familiar with its indications, surgical techniques, and timing.

   

  Jpn. J. Cardiovasc. Surg. 43:230-233（2014）

  Keywords：blunt cardiac trauma;cardiac rupture;Clamshell thoracotomy;descending aortic cross-clamping;hilar cross-clamping

  
  
• Giant Right Coronary Artery Aneurysm with Coronary Artery Fistula to Right Atrium R. Nomura et al.…234
  Giant Right Coronary Artery Aneurysm with Coronary Artery Fistula to Right Atrium
  
  

  Ryota Nomura	Masanao Nakai	Mitsuomi Shimamoto
  Fumio Yamazaki	Tatsuya Itonaga	Tatsuji Okada
  Yasuhiko Terai	Yuta Miyano and Yoshisuke Murata

  
  

  （Department of Cardiovascular Surgery, Shizuoka City Hospital, Shizuoka, Japan）
  

  We describe successful surgical treatment of a right coronary artery aneurysm associated with a fistula to the right atrium（RA). The patient was a 50-year-old man who complained of palpitations. ECG showed supraventricular extrasystole, and coronary CT revealed a remarkably dilated and undulating fistulous tract originating from the region corresponding to the orifice of the normal right coronary artery（RCA). The fistulous tract detoured to the posterior wall of the RA. An RCA of normal size originating from the midway of the fistulous tract was observed. The patient was operated on under cardio-pulmonary bypass. An aortocoronary bypass was performed, using a radial artery graft to section of the RCA that had a normal diameter. The RCA was subsequently ligated at the proximal side of the anastomosis. The orifice of the fistulous tract from the aorta was closed with a patch, and the entrance to the RA was also closed with mattress sutures. The postoperative recovery was uneventful, and he was discharged on the 19th postoperative day. Currently, the patient has been doing well without any complaints at 2 years postoperatively.

   

  Jpn. J. Cardiovasc. Surg. 43:234-237（2014）

  Keywords：right coronary artery to right atrium fistula;congenital coronary artery fistula;CABG

  
  

Editor’s Post Script

• K. Komori