Aortic Valve Replacement in a Patient with Primary Antiphospholipid Syndrome and Recurrent Cerebral Infarction / 日本心臓血管外科学会雑誌

A 61-year-old woman had a history of deep vein thrombosis of the right leg at the age of 36 years. Primary antiphospholipid syndrome (APS) had been diagnosed at the age of 38 years, and rapidly progressive glomerulonephritis had developed at 54 year. She started hemodialysis one month before presentation due to deterioration of renal function. This time, she presented to the emergency department with paroxysmal nocturnal dyspnea. Echocardiography showed severe combined aortic stenosis and regurgitation (ASR). It was considered that the combination of ASR and construction of an arteriovenous fistula for dialysis had led to congestive heart failure. The patient had also experienced headache and agraphia for several days. Therefore, brain MRI was performed and multiple cerebral infarcts were detected. Early surgery should be considered for ASR, but we planned delayed surgery owing to the complication of acute cerebral infarction. During follow-up observation, a new asymptomatic cerebral infarct was detected. Eventually, aortic valve replacement (AVR) with a biological valve was performed on day 38 of hospitalization. Because she had highly active primary APS, surgery was performed with oral administration of aspirin, followed by continuous systemic heparinization from the early postoperative period. No perioperative thrombosis or bleeding was noted, and the patient was discharged uneventfully on postoperative day 34.

Off-Pump Coronary Artery Bypass Graft in a Patient with Congenital Factor V Deficiency and Hereditary Spherocytosis Complicated with Stage 4 Diabetic Nephropathy / 日本心臓血管外科学会雑誌

<p>A 64-year-old man with congenital factor V deficiency and hereditary spherocytosis was attending our hospital for type II diabetes and stage 4 diabetic nephropathy. Coronary angiography performed to assess chest pain revealed severe triple-vessel disease, including total occlusion of the right coronary artery. The patient required surgical coronary revascularization. In the preoperative examination, the activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were high (89.5 s and 1.95) and factor V activity was low (6% ; normal range, 70-135%). Hemodialysis was performed on the day of the operation, and 6 units of fresh frozen plasma (FFP) were administered, which reduced immediately the preoperative PT-INR to 1.33. We performed off-pump coronary artery bypass grafting (OPCAB) and perioperatively administered 6 units of FFP with 4 units of red blood cells (RBC) transfusion. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 22. Here we report the case of a patient with a very rare disease of congenital factor V deficiency and hereditary spherocytosis complicated with stage 4 diabetic nephropathy who required OPCAB.</p>

A Surgical Case of Right Coronary Ostial Stenosis, Aortic Regurgitation, and Annuloaortic Ectasia Associated with Syphilitic Aortitis / 日本心臓血管外科学会雑誌

<p>We report a case of syphilitic aortitis (SA) associated with severe right coronary ostial stenosis, aortic regurgitation (AR), and annuloaortic ectasia (AAE). A 48-year-old man presented to a regional hospital with easy fatigability and nocturnal dyspnea. Echocardiography revealed Seller's grade 3 AR. A computed tomography scan showed AAE, dilatation of the ascending aorta, and calcification of both coronary ostia. Coronary angiography demonstrated that the left coronary artery was intact ; however, the right coronary artery was obscure. Active syphilis was detected on routine blood tests on admission. Therefore, the patient was started on a course of ampicillin/sulbactam (ABPC/SBT). Subsequently, he underwent the Bentall procedure and coronary artery bypass grafting with the right internal thoracic artery. The intraoperative findings showed degeneration of the aorta and severe right coronary ostial stenosis. The pathological findings of the aortic wall and aortic valve were consistent with SA. The postoperative course was uneventful. The patient continued receiving ABPC/SBT for 3 weeks postoperatively, and was then switched to oral amoxicillin.</p>

Liver Fibrosis Markers Reflect the Quality of Fontan Circulation / 日本心臓血管外科学会雑誌

<b>Background</b> : Several studies have shown that Fontan circulation may lead to liver congestion and possible structural liver alteration. The aim of this study is to analyze the relationships between biochemical fibrosis markers and hemodynamic parameters in the long term after the Fontan operation.<br><b>Methods</b> : The study enrolled 51 patients who underwent total cavopulmonary connection between March 1994 and July 2010. We analyzed the relationships between the 5 liver fibrosis markers (hyaluronic acid, retinol-binding protein, procollagen type III peptide, type IV collagen 7S, type IV collagen) and the 6 hemodynamic parameters (pulmonary artery pressure, pulmonary artery index, pulmonary vascular resistance, ejection fraction, atrioventricular valve regurgitation, cardiac index).<br><b>Results</b> : Hyaluronic acid and type IV collagen 7S positively correlated with pulmonary artery pressure. Hyaluronic acid negatively correlated with ejection fraction, and type IV collagen 7S positively correlated with atrioventricular valve regurgitation in patients followed up for more than 8 years after Fontan completion. Pulmonary artery pressure was significantly higher in patients in whom type IV collagen 7S was elevated. Hyaluronic acid correlated with pulmonary vascular resistance (<i>p</i>=0.0035) and ejection fraction (<i>p</i>=0.014), as well as type IV collagen 7S with pulmonary artery pressure (<i>p</i>=0.0001) by multiple regression analysis.<br><b>Conclusion</b> : Hyaluronic acid and type IV collagen 7S reflected the degree of hepatic congestion, and cardiac function, in the long term after the Fontan operation.

Outcome of Arterial Reconstruction for Intermittent Claudication and Limb-Threating Ischemia / 日本心臓血管外科学会雑誌

To determine the usefulness of arterial reconstruction, we studied the outcome of 430 patients with arteriosclerosis obliterans who had received either arterial reconstructive surgery or medical treatment. Of the 430, 301 patients were treated for intermittent claudication and 162 for limb-threating ischemia (rest pain or ischemic gangrene). Of the intermittent claudication patients 274 underwent arterial reconstruction and 27 were treated with anticoagulant therapy. In limb-threating ischemia, 137 patients underwent arterial reconstruction and 25 were treated with anticoagulant therapy. Among the 274 intermittent claudication patients treated by arterial reconstruction, none required major amputation within 30 days after surgery. Operative mortality was 1.1%. Five- and ten- year comulative patency rates were 95.4%, 94.3% in aortofemoral bypasses, 72.7%, 67.5% in aortofemoropopliteal bypasses, 79.7%, 77.9% in femoropopliteal bypasses and 92.3%, 92.3% in femorotibial bypasses, respectively. On long-term results, 86.4% improved and 5.9% deteriorated. Five patients (1.4%) underwent major amputation during the follow-up period due to graft occlusion. Four of 5 amputations involved patients whose initial reconstruction method was femoropopliteal bypass. In 27 patients treated medically, 77.8% did not show any change in symptoms and 22.2% deteriorated during the follow-up period. Two patients (5.6%) underwent bypass grafting in the late phase. Of 137 patients with limb-threating ischemia treated by arterial reconstruction, 3.3% required major amputation in the early postoperative period. Operative mortality was 5.1%. Five- and 10-year cumulative patency rates were 83.3%, 79.7% in aortofemoral bypasses, 65.5%, 65.5% in aortofemoropopliteal bypasses, 76.2%, 63.9% in femoropopliteal bypasses and 38.6% in femorotibial bypasses, respectively. In long-term results, 62.3% improved and 12.6% deteriorated. Thirteen patients (8.6%) underwent major amputation during the follow-up period. In 25 patients with limb-threating ischemia treated medically, 16.0% died during their hospital stay and 33.3% required major amputation during the follow-up period. Five- and 10-year cumulative survival rates in arterial reconstruction patients were 77.4%, 57.6% in intermittent claudication patients and 64.3%, 41.5% in limb-threating ischemia patients, respectively. The survival rate in limb-threating ischemia was significantly lower than that in intermittent claudication. The results of reconstructive surgery for intermittent claudication were better than those of medical treatment. However, 4 femoropopliteal bysass cases required major amputation in the late phase. This suggests that it is difficult to determine the indications for infrainguinal artery reconstruction in intermittent claudication. Arterial reconstructive surgery for limb-threating ischemia was useful for salvaging the limbs. In these patients, careful perioperative treatment was necessary. Limb salvage rate and survival rate in limb-threating ischemia patients were poorer than those in intermittent claudication patients. We recommend performing arterial reconstructive surgery for disabling claudication before the patient progresses to limb-threating ischemia.