A Pseudoaneurysm of the Left Internal Iliac Artery after Intravesical Bacillus Calmette-Guerin Therapy / 日本心臓血管外科学会雑誌

We report a case of pseudoaneurysm of the left internal iliac artery after intravesical Bacillus Calmette-Guerin (BCG) therapy for bladder cancer. A 75-year-old man was referred to us with lumbar pain and recurring fever. One year previously he was treated for bladder cancer with transurethral resection, followed by adjuvant intravesical BCG therapy lasting 11 months. Computed tomography scanning demonstrated a pseudoaneurysm and perianeurysmal inflammatory changes in the region of the left internal iliac artery. An emergency operation was performed under a diagnosis of impending rupture of the tuberculous left internal iliac arterial aneurysm. Because of the urinary tract stenosis, which was caused by the aneurysm, we inserted a ureteral stent preoperatively. We performed aneurysmectomy and femorofemoral cross over bypass. After 10 months of antituberculous chemotherapy, CT showed no recurrence of infectious aneurysm. Although intravesical BCG therapy is generally considered safe, serious complications including vascular complication have been reported. A mycotic origin should be considered when an aneurysm is discovered after BCG therapy. The prophylactic use of a ureteral stent in mycotic iliac arterial surgery may lead to minor complications.

Repair of Recurrent Congenital Mitral Insufficiency Using Folding Plasty / 日本心臓血管外科学会雑誌

A 13-year-old girl with congenital mitral incompetence had undergone valvoplasty using the De Vega technique at age 5. The patient was referred by the pediatric department due to recurrence of mitral incompetence. Transesophageal echocardiography indicated regurgitation from A2 and P3, mild mitral leaflet tethering and left ventricular dilatation. Intraoperative findings showed valvular agenesis of the posterior leaflet around P3. No leaflet prolapse was observed at A2, but leaflet P2 had fallen to the left ventricular side compared with leaflet A2, thereby inducing regurgitation due to coaptation gap. In a procedure similar to folding plasty, leaflet P3 was folded down and sutured to the annulus extending up to the posteromedial commissure. This technique not only controlled regurgitation at P3 but also improved the coaptation between A2 and P2. Annuloplasty was conducted using a 28-mm Physio-ring. Folding plasty may be an effective surgical option for patients with congenital mitral incompetence because a broad valve orifice area can be maintained because there is no need for annular plication.

Lower Mid-line Skin Incision with Full Sternotomy as an Approach for Pediatric Atrial Septal Defect Repair / 日本心臓血管外科学会雑誌

Recently, the demand for better cosmetic outcomes in pediatric cardiovascular operations has been growing. Between May 1998 and April 1999, six children aged 2 to 6 years with an ostium secundum type of atrial septal defect underwent reparative operations that used an approach consisting of a lower mid-line skin incision with full sternotomy. A 4.2-5.8cm vertical skin incision (mean, 4.9±0.3cm) was made between the level of the nipple and the xyphoid process. Comparison between this series and a group of weight-matched patients who underwent conventional operations revealed no significant differences in operation time (166.0±12.0vs. 147±8.4min), cardiopulmonary bypass time (33.2±4.0vs. 32.2±2.4min), aortic cross-clamp time (13.8±2.3vs. 12.3±1.3min), or the reduction in the hemoglobin concentration in blood on the first postoperative day (1.7±0.3vs. 2.9±0.6g/dl). The surgical wound was not associated with any complications in our series, including wound infection or subcutaneous hematoma. Our technique appears to be safe and provide satisfactory cosmetic outcome.

Long-Term Follow-up of Patients with valvular and Non-valvular Extracardiac Conduits / 日本心臓血管外科学会雑誌

Here we present a long-term follow-up of 50 operative survivors, who underwent surgery between December 1975 and March 1994 for the placement of an extracardiac conduit. Twenty-six patients received conduits with various valves (VC group). The valves used were the Hancock valve in 9 patients, the St. Jude Medical valve in 5, and a valved roll made of equine pericardium in 10. Twenty-four patients received valveless Dacron conduits (NVC group). Another group of patients, also with discontinuity between the right ventricle and the pulmonary artery, who were operated on without the use of a conduit, is presented here for comparison (NCR group: 16 patients). The follow-up period for the NCR group was shorter than for the other groups. There were a total of 4 late deaths in the conduit groups, and none in the NCR group. Freedom from reoperation due to conduit stenosis was analyzed by the Kaplan-Meier method. In the VC group, freedom from reoperation at 5, 10, and 15 years, was 87.8%, 50.8%, and 31.2% respectively. In the NVC group, freedom from reoperation at 5, 10, and 15 years was 100%, 95.7%, and 60.4%. There were statistically significant differences between the values in these 2 groups. In the NCR group, only one patient (6.25%) underwent reoperation due to stenosis in the right ventricular outflow tract. Although the rate of freedom from reoperation was lower in the valveless conduit group than in the valved conduit group, the majority of patients who receive a conduit between the right ventricle and the pulmonary artery will eventually require reoperation. Avoiding the use of an extracardiac conduit, and creating continuity between the right ventricle and pulmonary artery with autologous tissue is a useful alternative and may reduce the need for reoperation.