A Case of Surgical Treatment of Anomalous Origin of the Single Coronary Artery from the Pulmonary Artery / 日本心臓血管外科学会雑誌

A 2-month-old male infant was transferred to our hospital for suspected cardiomyopathy because he had livedo reticularis and peripheral coldness. An electrocardiogram showed ischemic change and an echocardiogram showed a dilated, poorly functioning left ventricle. Therefore, we performed urgent cardiac catheterization. The coronary artery was not visualized by aortography, but the single coronary artery arising from the pulmonary artery was depicted by pulmonary angiography. Therefore, we performed emergent surgery. The whole coronary arteries traveled directly inferiorly from the left side of the pulmonary trunk. A patent ductus arteriosus (PDA) was closed at the operation. We established cardiopulmonary bypass using two arterial cannulae through both ascending aortas and pulmonary trunk to maintain coronary blood flow. Direct implantation is difficult because the coronary ostium is far from the ascending aorta. Therefore, we chose to perform the Takeuchi procedure using an intrapulmonary artery tunnel. The patient's postoperative course was good, and he was discharged on postoperative day 22. A case of an anomalous origin of a single coronary artery from the pulmonary artery without any other heart disease is extremely rare. Management of cardiopulmonary bypass and myocardial protection in this abnormality is discussed.

Total Arch Replacement for Acute Type A Aortic Dissection 5 Years after Aortic Valve-Sparing Operation in a 14-Year-Old Boy with Loeys-Dietz Syndrome / 日本心臓血管外科学会雑誌

A 14-year-old boy who underwent aortic valve-sparing operation for annuloaortic ectasia at the age of 9 was referred to our service with a diagnosis of acute type A aortic dissection. Emergency total arch replacement with the elephant trunk technique was done successfully and the postoperative course was uneventful. However, computed tomography (CT) 2 weeks after the operation showed a new dissection and enlargement in left subclavian artery and folded elephant trunk. Dilatation in coronary buttons were also seen since the time of surgery. No residual dissection was found in the aorta. Careful follow up is necessary for this case due to multiple aneurysmal changes and a new dissection lesion in a short period. Loeys-Dietz syndrome (LDS) is characterized by vascular findings (aortic aneurysm and dissection) and skeletal manifestations. Due to aortic dissection occurring in smaller diameter aortas in LDS patients than in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS.

Effectiveness of Wound Infection Control in Open Heart Surgery for Neonates and Infants less than Three Months Old / 日本心臓血管外科学会雑誌

The incidence of wound infection and delayed wound healing was greater in neonates and infants less than 3 months old who had undergone open heart surgery through a median sternotomy than in older patients. To reduce these problems, we stopped using continuous absorbable braided suture for skin and subcutaneous tissue closure in August 2005, and used interrupted non-absorbable monofilament suture instead. Around the same time, we adopted hydrocolloid dressing as a substitute for gauze dressing. We evaluated the effectiveness of wound management by comparing 28 patients who had undergone surgery before August 2005 with 22 patients who underwent surgery after that date. The age at surgery was 45±30 and 21±23 days, respectively. The patients in the earlier period were significantly older than in the later period. There were no significant differences in body weight at surgery, operating time, or cardiopulmonary bypass time between the groups. The time for wound closure was 30±11 and 22±4 min, respectively, and the patients were hospitalized after surgery for 61±41 and 44±31 days. Both were significantly shorter in the later group of patients. There was a single case of mediastinitis, in the earlier period. Wound infection or delayed wound healing occurred in 8 patients in the earlier period and in 3 patients in the later period. The only 4 patients who required wound resuturing were all in the earlier period. The incidence of wound infection and delayed wound healing tended to be low in the later period. We believe that interrupted non-absorbable monofilament sutures improved the wound microcirculation and that the hydrocolloid dressing accelerated wound healing via its moisturizing and heat-retention action, pH buffering ability, and bacteriostatic activity, and that all these contributed to the better outcomes in the later period.

A Case of Primary Chylopericardium in Which Three-Dimensional Computed Tomography Scan with Lymphangiography Was Useful / 日本心臓血管外科学会雑誌

A 36-year-old previously healthy woman with cardiomegaly on a routine chest X-ray was given a diagnosis of primary chylopericardium after pericardial puncture revealed milky effusion. Endoscopy-assisted ligation of the thoracic duct and creation of a pericardial window was performed. The operation was greatly facilitated by the preoperative three-dimensional CT scan with lymphangiography that precisely demonstrated the distribution of the thoracic duct and other lymphatic ducts.

Successful Surgical Repair of Impending Rupture of a Pseudoaneurysm of the Brachiocephalic Artery with Prior Reconstruction of the Carotid Artery / 日本心臓血管外科学会雑誌

We report the successful repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery (BCA) in a 70-year-old man. He had undergone a mediastinal tumor resection through a median sternotomy in 1995. Pathological examination revealed non-Hodgkin's lymphoma. Two years later, he underwent radiation therapy of 65 Gray for metastasis to the supraclavicular lymph nodes. On January 18, 2000, plastic surgeons planned to perform a pectoralis major musculocutaneous flap to repair a radiation skin ulcer. During the operation, the BCA was lacerated, possibly in an area of radiation tissue damage. We performed a prosthetic graft (10-mm Gelseal^TM) replacement of the BCA. The right subclavian artery had to be ligated. Postoperative digital subtraction angiography (DSA) showed excellent reconstruction of the artery. Magnetic resonance angiography of the brain showed a deficit in the anterior communicating artery and stenosis of the posterior communicating artery, which indicated that the reconstruction procedure was reasonable. Seven months later, on August 18, 2000, the patient was transferred to our hospital because of swelling of the right neck and oozing from the previous cutaneous wound. CT scan and DSA demonstrated the presence of a pseudoaneurysm of the proximal anastomosis site, which required emergency surgery. Before this third sternotomy, a saphenous vein graft was interposed between both external carotid arteries. Removal of the prosthetic graft and resection of the pseudoaneurysm were performed under mild hypothermia and cardiopulmonary bypass with left common carotid arterial perfusion. Then, the wound was closed completely using a left pectoralis major musculocutaneous flap. The postoperative course was uneventful and DSA showed good patency of the graft and intracranial arteries. The patient was discharged without neurological complications. We conclude that prior reconstruction of the carotid artery is a safe and effective procedure for patients with aneurysmal changes in the BCA, especially in the case of re-operation.

Left Thoracotomy in the Treatment of Ruptured Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

Thirteen cases of ruptured abdominal aortic aneurysm were treated during a period of 7 years and 5 months. In 6 cases, left thoracotomy was used before laparotomy to clamp the descending thoracic aorta. The merits and demerits of this method were evaluated in this study. It is useful for early improvement of cerebral and coronary circulation and prevention of sudden spurting hemorrhage, especially in cases with the previous laparotomies. On the other hand, this method has a shorter clamp time limit and requires much time in cases with pleural adhesions. It may increase the amount of operative bleeding and the incidence of postoperative respiratory insufficiency. It may also cause an intraoperative thoracic aortic dissection and rupture of thoracic aortic aneurysms if present. It is considered that this method is advantageous, but should be used only in selected cases.