Japanese Journal of Cardiovascular Surgery Vol43,No6

Preface

• “U-40” Project　H. Shimpo

Originals

• Surgical Outcomes of Left Ventricular Free Wall Rupture and Ventricular Septal Perforation after Acute Myocardial Infarction N. Horio et al.…305
  Surgical Outcomes of Left Ventricular Free Wall Rupture and Ventricular Septal Perforation after Acute Myocardial Infarction
  
  

  Naohiro Horio

  Hideki Teshima

  Masahiko Ikebuchi and Hiroyuki Irie

  
  

  （Cardiovascular Surgery, Chikamori Hospital Heart Center, Kochi, Japan）
  

  Objective:To investigate the surgical outcomes of left ventricular free wall rupture（LVFWR）and ventricular septal perforation（VSP）in terms of mechanical complications following acute myocardial infarction（AMI). Methods:Subjects comprised 26 patients（male:12, female:14, mean age:74 years）who underwent surgery between 2001 and 2012. The LVFWR type was blowout in 2 cases and oozing in 5 cases. Immediately after diagnosis, 4 cases underwent intra-aortic balloon pumping（IABP）and 2 cases received extracorporeal membrane oxygenation（ECMO). LVFWR was repaired by suture and patch closure in 5 patients and by TachoComb in 2 patients. VSP was caused by anterior infarction in 15 cases and inferior infarction in 5 cases. IABP was inserted in 16 cases. VSP was repaired by the infarct exclusion technique in 17 patients, while 2 patients underwent suture or patch closure. Results:The operative mortality rate was 14.3% for LVFWR and 15.8% for VSP. The cause of operative death in 1 patient with blowout type LVFWR who was in a state of cardiopulmonary arrest on arrival, was low cardiac output syndrome（LOS). The causes of operative death in VSP included 2 patients with LOS and 1 patient who died suddenly 8 days postoperatively due to ventricular fibrillation. Two VSP patients underwent repeat surgery for residual shunt. The five-year Kaplan-Meier survival rates were 85% for LVFWR and 62% for VSP. Of 20 patients who received IABP preoperatively, the time from confirming LVFWR or VSP diagnosis after admission to IABP initiation was 103±45（48-120）min in the survival group（n＝17）and 259±174（122-455）min in the operative mortality group（n＝3). A significant difference was observed between the two groups（p＝0.04). Conclusion:Therapeutic strategies including rapid diagnosis after admission, early insertion of IABP, and prompt surgery could improve the prognosis for patients with LVFWR and VSP following AMI.

   

  Jpn. J. Cardiovasc. Surg. 43:305-309（2014）

  Keywords：acute myocardial infarction;ventricular septal perforation;left ventricular free wall rupture

  
  

Case Reports

• A Penetrating Cardiac Injury by a Sewing Needle T. Sano et al.…310
  A Penetrating Cardiac Injury by a Sewing Needle
  
  

  Toshikazu Sano

  Hideki Teshima

  Ryuta Tai

  Masahiko Ikebuchi and Hiroyuki Irie

  
  

  （Cardiovascular Surgery, Chikamori Hospital Heart Center, Kochi, Japan）
  

  A 24-year-old woman, under the treatment for atypical depression, visited our emergency room on foot with a chief complaint that she stabbed herself in the chest with a sewing needle. Chest X-ray and plain CT showed the needle penetrating the chest into the heart. There was no sign of pneumothorax or cardiac tamponade. She was hemodynamically stable. Echocardiography revealed atrial septal defect（ASD）by chance. We performed urgent surgery for needle removal and ASD closure through median sternotomy. The needle was easily recognized near the right ventricle apex. The right atrium was opened, but the needle was not seen through the tricuspid valve because of trabecular formation. After the needle was removed, ASD was closed using the direct suture method. The needle was 35mm long. She was transferred to the psychiatry department on postoperative day 4 and had a good postoperative course.

   

  Jpn. J. Cardiovasc. Surg. 43:310-312（2014）

  Keywords：foreign body in the heart;penetrating cardiac injury

  
  
• Mitral Valve Replacement via Right Thoracotomy for Ischemic Mitral Regurgitation in a Patient with Prior Coronary Artery Bypass Grafting C. Ueki et al.…313
  Mitral Valve Replacement via Right Thoracotomy for Ischemic Mitral Regurgitation in a Patient with Prior Coronary Artery Bypass Grafting
  
  

  Chikara Ueki

  Genichi Sakaguchi

  Takehide Akimoto and Tsunehiro Shintani

  
  

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

  We report a case of redo mitral valve replacement via right thoracotomy for ischemic mitral regurgitation after coronary artery bypass grafting. An 81-year-old woman with a history of multiple coronary artery bypass grafting was admitted to our institute for treatment of severe ischemic mitral valve regurgitation. She had a history of repeated hospitalization for heart failure and complained of worsening dyspnea. Coronary angiography showed patent coronary grafts. Echocardiography revealed severe mitral regurgitation with leaflet tethering and posteroinferior wall asynergy. The patient underwent mitral valve replacement（Mosaic Bioprosthesis 27mm）via right thoracotomy approach with ventricular fibrillation under moderate hypothermia. The ventricular fibrillation time was 57 min, and the cardiopulmonary bypass time was 126 min. The patient’s postoperative recovery was uneventful. She was discharged on postoperative day 19. Right thoracotomy approach provided excellent exposure of the mitral valve and minimized the risk of repeat sternotomy, including injury of previous bypass grafts, injury of right ventricle and significant hemorrhage.

   

  Jpn. J. Cardiovasc. Surg. 43:313-317（2014）

  Keywords：redo surgery;ischemic mitral regurgitation;right thoracotomy;mitral valve replacement

  
  
• A Case of Endovascular Repair of Iatrogenic Arterial Injury with an Aberrant Right Subclavian Artery J. Osaki et al.…318
  A Case of Endovascular Repair of Iatrogenic Arterial Injury with an Aberrant Right Subclavian Artery
  
  

  Jun Osaki	Junji Yunoki	Atsutoshi Tanaka
  Hiroaki Yamamoto	Hisashi Sato	Hiroyuki Morokuma
  Keiji Kamohara	Koujiro Furukawa and Shigeki Morita

  
  

  （Department of Cardiovascular Surgery, Saga University Hospital, Saga, Japan）
  

  A 61-year-old man underwent percutaneous coronary intervention（PCI）for the right coronary artery. However, he had an acute onset of right neck pain and swelling after PCI. Contrast enhanced computed tomography（CT）revealed extravasation into the mediastinum and aberrant right subclavian artery. After transfer to our hospital, we performed emergency endovascular repair for iatrogenic arterial injury. His postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 43:318-321（2014）

  Keywords：aberrant right subclavian artery;iatrogenic;vascular injury;endovascular repair

  
  
• Debranching and Endovascular Repair for Kommerell’s Diverticulum Involving Right-Sided Aortic Arch with Mirror Image Branching S. Kamihira et al.…322
  Debranching and Endovascular Repair for Kommerell’s Diverticulum Involving Right-Sided Aortic Arch with Mirror Image Branching
  
  

  Satoshi Kamihira

  Masanobu Yamauchi

  Tadashi Kitano and Kengo Nakayama

  
  

  （Department of Cardiovascular Surgery, Shimane Prefectural Central Hospital, Izumo, Japan）
  

  A 71-year-old man with an abnormal shadow on chest x-ray was given a diagnosis of Kommerell’s diverticulum involving the right-sided aortic arch with mirror image branching. Furthermore, mild funnel chest had been seen on CT scan more than 10 years earlier. The patient was followed up because there were no symptoms;the Kommerell’s diverticulum expanded to reach 63mm in diameter. To eliminate the risk of rupture, we performed thoracic endovascular aortic repair（TEVAR）with a commercially available device, consisting of bypass grafting of the supra-aortic branches. The patient was discharged from the hospital in good clinical condition, with no signs of endoleak and currently shows no indications of device migration. We thus concluded that debranching TEVAR for Kommerell’s diverticulum with right-sided aortic arch is minimally invasive, safe, and effective. Availability of this device that has a new performance feature is expected to improve treatment results and lead to advances in minimally invasive endovascular repair.

   

  Jpn. J. Cardiovasc. Surg. 43:322-325（2014）

  Keywords： right aortic arch;Kommerell’s diverticulum;debranching;thoracic endovascular aortic repair（TEVAR）

  
  
• Two Infant Cases with Pulmonary Atresia, Intact Ventricular Septum, Right Ventricle-Dependent Coronary Circulation, and Myocardial Ischemic Symptoms S. Yamauchi et al.…326
  Two Infant Cases with Pulmonary Atresia, Intact Ventricular Septum, Right Ventricle-Dependent Coronary Circulation, and Myocardial Ischemic Symptoms
  
  

  Sanae Yamauchi	Hiroaki Kawata	Shigemitsu Iwai
  Kanta Araki	Motoki Komori and Hidefumi Kishimoto

  
  

  （Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan）
  

  We describe two cases with pulmonary atresia, intact ventricular septum（PA/IVS), and right ventricle-dependent coronary circulation, who suffered from myocardial ischemic symptoms. Case 1:A female infant diagnosed with PA/IVS during the fetal period was born after 40 weeks of gestation, weighing 3,078g. Aortography demonstrated that the right coronary artery（RCA）was interrupted at the proximal segment, and the left coronary artery（LCA）did not show any stenosis. Right ventriculogram revealed sinusoidal connections filling the distal part of the right coronary artery and fistulous communications to the left anterior descending artery. Temporary ST segmental depression in ECG during milk feeding or crying improved spontaneously with time. Bidirectional Glenn shunt（BDG）was performed at 3 months old, and she underwent Fontan repair at 4 years old. She is doing well with no evidence of myocardial ischemic change. Case 2:A female infant was born after 39 weeks of gestation, weighing 3,062g. Aortography demonstrated that the RCA was interrupted at the middle segment, and the distal area depended on the right ventricle. LCA ostium at the ascending aorta was absent. Multiple sinusoidal connections were seen in the right ventricular myocardium with filling of the LCAs but no reflux into the aortic sinuses. After ventricular tachycardia occurred at 2 months old, left ventricular function deteriorated. BDG with ligation of the arterial duct was performed at age 3 months. The arterial blood pressure was 76/53（62）mmHg and pressure in SVC was 21mmHg immediately after the operation. However, arterial oxygen saturation, right atrium venous oxygen saturation and left ventricular ejection fraction were 50%, 16%, and 10%, respectively. Although extracorporeal membrane oxygenation was established for circulatory and myocardial oxygenation support on the postoperative day 2, her left ventricular function did not recover and she died on postoperative day 5. It is difficult to rescue such a case in which almost all coronary circulation depends on the right ventricle filled with desaturated blood.

   

  Jpn. J. Cardiovasc. Surg. 43:326-330（2014）

  Keywords： pulmonary atresia with intact ventricular septum;right ventricle-dependent coronary circulation;myocardial ischemia;bidirectional Glenn shunt

  
  
• A Case of Constrictive Pericarditis after Open-Heart Surgery Effectively Treated with Pericardiectomy N. Hayashi et al.…331
  A Case of Constrictive Pericarditis after Open-Heart Surgery Effectively Treated with Pericardiectomy
  
  

  Nagi Hayashi	Kojiro Furukawa	Hideya Tanaka
  Hiroyuki Morokuma	Manabu Itoh	Keiji Kamohara and Shigeki Morita

  
  

  （Department of Thoracic and Cardiovascular Surgery, Saga University, Saga, Japan）
  

  Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5l/min/m2 to 2.7l/min/m2, and central venous pressure improved from 17 to 10mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.

   

  Jpn. J. Cardiovasc. Surg. 43:331-335（2014）

  Keywords： constrictive pericarditis;pericardiectomy;post cardiac surgery

  
  
• Single-Stage Repair of Thoracic Aortic Aneurysm Associated with Aortic Stenosis and Pseudocoarctation by Means of the Clamshell Approach T. Shibukawa et al.…336
  Single-Stage Repair of Thoracic Aortic Aneurysm Associated with Aortic Stenosis and Pseudocoarctation by Means of the Clamshell Approach
  
  

  Takanori Shibukawa	Yuhya Tauchi	Naoki Okuda
  Mitsutomo Yamada	Hisashi Satoh and Hikaru Matsuda

  
  

  （Department of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan）
  

  A 64-year old man was admitted to our hospital with a diagnosis of aortic stenosis. Pre-operative chest CT revealed pseudocoarctation of the aorta with a hypoplastic aortic arch, elongation and kinking of the aortic arch and proximal descending aorta. There was also a large aneurysm from the distal arch to descending aorta. We performed a single-stage repair of the aortic lesion from the ascending to the descending aorta with aortic valve replacement. For the surgical approach, transverse clamshell incision was applied safely. Concomitant aortic valve replacement in surgical repair of pseudocoarctation and thoracic aneurysm was rare, and clamshell incision seemed beneficial in such single-stage repair from the aortic root to the descending aorta.

   

  Jpn. J. Cardiovasc. Surg. 43:336-339（2014）

  Keywords： aortic stenosis;pseudocoarctation;thoracic aortic aneurysm;clamshell incision

  
  
• Successful Treatment for Persistent Air Leaks with an Autologous “Blood Patch” Pleurodesis after the Norwood Procedure H. Tatewaki et al.…340
  Successful Treatment for Persistent Air Leaks with an Autologous “Blood Patch” Pleurodesis after the Norwood Procedure
  
  

  Hideki Tatewaki	Toshihide Nakano	Kazuhiro Hinokiyama
  Noriyoshi Ebuoka	Hidekazu Matsumae	Daisuke Machida
  Takahiro Shoujima	Jin Ikarashi	Ryuji Tominaga and Hideaki Kado

  
  

  Department of Cardiovascular Surgery, Fukuoka Children’s Hospital, Fukuoka, Japan, and Department of Cardiovascular Surgery Graduate School of Medical Science, Kyushu University, Fukuoka, Japan）
  

  Persistent massive air leak after pediatric cardiac surgery is a rare and possibly life-threatening complication which is difficult to treat. We report a 3-month-old boy with hypoplastic left heart syndrome that underwent Glenn take-down, suffered from pulmonary hemorrhage during surgery and needed mechanical ventilation with high airway pressure that caused bilateral pneumothorax. After pulmonary hemorrhage improved, pneumothorax with persistent air leaks did not resolve under prolonged chest tubes. This patient underwent an autologous “blood patch” pleurodesis on postoperative day 32. The procedure was repeated a second time 48 h after the application of the first blood patch. After these procedures, air leaks dramatically ceased. The patient was successfully weaned from the ventilator on postoperative day 70. Pleurodesis with an autologous blood patch is a safe and an effective technique for the treatment of persistent air leaks, even for a 3-month-old boy with hypoplastic left heart syndrome.

   

  Jpn. J. Cardiovasc. Surg. 43:340-343（2014）

  Keywords： hypoplastic left heart syndrome;persistent air leak;autologous blood patch pleurodesis

  
  
• A Case of Acute Aortic Regurgitation due to Leaflet Dehiscence of the Carpentier-Edwards Pericardial Bioprosthesis 18 Years after Implantation S. Otani et al.…344
  A Case of Acute Aortic Regurgitation due to Leaflet Dehiscence of the Carpentier-Edwards Pericardial Bioprosthesis 18 Years after Implantation
  
  

  Satoru Otani

  Tsuyoshi Yamamoto

  Yuki Yamada and Taiichiro Matsumoto

  
  

  （Department of Cardiovascular Surgery, Iwakuni Clinical Center, Iwakuni, Japan）
  

  A 65-year-old man, who had undergone the aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis（CEP 25mm）18 years previously（at age 48), was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. Redo surgery was performed. 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, the other two leaflets of CEP were severely calcified. Aortic valve replacement was performed with a CEP 23mm. He was discharged in good condition on the 16th post-operative day.

   

  Jpn. J. Cardiovasc. Surg. 43:344-346（2014）

  Keywords： acute aortic regurgitation;pericardial bioprosthesis;bovine pericardial valve;leaflet dehiscence

  
  
• Prosthetic Valve Endocarditis due to Corynebacterium striatum T. Fujimiya and S. Takahashi…347
  Prosthetic Valve Endocarditis due to Corynebacterium striatum
  
  

  Tsuyoshi Fujimiya and Shoichi Takahashi

  
  

  （Department of Cardiovascular Surgery, Hoshi General Hospital, Koriyama, Japan）
  

  There are few reports of prosthetic valve endocarditis due to Corynebacterium striatum. Here we report a case of prosthetic valve endocarditis after mitral valve replacement. A 77-year-old woman, who underwent mitral valve replacement and tricuspid valve annulo-plasty 4 months previously, was admitted to our hospital because of shock and loss of consciousness. A transthoracic echocardiogram showed severe mitral regurgitation due to dehiscence of the prosthetic mitral valve. We used the percutaneous cardiopulmonary support system for the management of circulatory collapse and, performed emergency mitral valve replacement. We detected C. striatum in preoperative blood and vegetation cultures. Antibiotic therapy was continued for 6 weeks, and the patients recovered without any complications.

   

  Jpn. J. Cardiovasc. Surg. 43:347-350（2014）

  Keywords： prosthetic valve endocarditis;Corynebacterium striatum

  
  
• Efficacy of the Amplatzer Vascular Plug in a Patient Undergoing EVAR for Ruptured Aortoiliac Aneurysm T. Akiyoshi et al.…351
  Efficacy of the Amplatzer Vascular Plug in a Patient Undergoing EVAR for Ruptured Aortoiliac Aneurysm
  
  

  Takurin Akiyoshi	Masanori Inoue	Tomoki Tamura
  Takuma Fukunishi and Hideaki Obara

  
  

  （Division of Vascular Surgery, Department of Surgery, Department of Radiology, Department of Surgery, Hiratsuka City Hospital, Hiratsuka Japan, and Department of Surgery, Keio University Hospital, Tokyo, Japan）
  

  The purpose of this case report was to discuss the efficacy of The Amplatzer Vascular Plug（AVP）in endovascular aneurysm repair（EVAR）for ruptured aortoiliac aneurysm. A 73-year-old man was referred to our institution with a diagnosis of ruptured abdominal aortic aneurysm（rAAA）by CT scan. The CT scan showed an rAAA of 70mm（Fitzgerald classification 3）and a right common iliac aneurysm of 30mm. The patient was immediately transferred from the ER to the OR and treated with EVAR in combination with occlusion of the right internal iliac artery（IIA）using AVP. The total procedural time was 138 min. The patient recovered uneventfully after the operation with an ICU stay of 2 days and was discharged 9 days after the onset. EVAR has been recognized as a therapeutic option for rAAA in Japan. However, it is not yet been generally adopted as a first-line therapy for rAAA accompanied with iliac aneurysm because of the necessity to occlude IIA. The conventional method with coils to induce thrombosis of IIA is unsuitable for patients in a critical situation for the time required and the difficulty in precise placement. AVP is a nitinol-based self-expanding cylindrical device that is used for arterial embolization. AVP allows assured embolization of IIA in a shorter procedural time, which is essential in an urgent situation. Although AVP is still under post-market surveillance in Japan and only available in limited institutions, the usage of AVP should be considered as an adjunctive procedure in EVAR for rAAA and may expand the limits of endovascular treatment for rAAA.

   

  Jpn. J. Cardiovasc. Surg. 43:351-356（2014）

  Keywords： ruptured abdominal aortic aneurysm;aortoiliac aneurysm;EVAR;occlusion of hypogastric artery;Amplatzer Vascular Plug

  
  

Editor’s Post Script

• H. Yaku