A Surgical Case of Stanford Type A Acute Aortic Dissection Concomitant with Paraplegia / 日本心臓血管外科学会雑誌

A 76-year-old man who suffered from consistent back pain was admitted for anti-hypertensive therapy to strictly manage the early thrombosed acute type A aortic dissection (AAAD). On admission, his blood pressure could not be controlled well ; soon he complained of recurrent severe back pain. The second thoracoabdominal enhanced computed tomography revealed the progression of AAAD from DeBakey type II to type I with thrombosed pseudolumen at the descending thoracic aorta ; therefore, emergent surgical intervention by primary central repair was conducted. Paraplegia was diagnosed eight hours after surgery, then cerebrospinal fluid drainage and intravenous administration of Naloxone were started immediately followed by keeping the systemic blood pressure more than 120 mmHg. However, paraplegia had never improved and been persistent with neurological deficit of the lower extremities. We herein report a complicated surgical case of an AAAD patient with paraplegia and review the complex clinical settings.

A Surgical Case of Fourth Reoperation Using a Unique Technique of Cardioplegia / 日本心臓血管外科学会雑誌

The method of cardioplegic myocardial protection is often controversial for re-cardiotomy after a coronary artery bypass grafting (CABG). A 69-year-old woman with a history of three previous surgeries consisting of closed mitral commissurotomy (CMC), dual valve replacement (DVR), and CABG underwent mitral valve replacement (MVR) and CABG for perivalvular leakage (PVL). As a result, the bilateral coronary ostium and the bypass graft to the right coronary artery (RCA) were totally occluded. The left internal thoracic artery (LITA) graft to the left anterior descending (LAD) coronary artery was the only inflow to the left coronary artery system and the right coronary artery system developed collateral inflow. Cardioplegia was carried out by performing a temporary anastomosis graft on the saphenous vein graft (SVG) in the left anterior descending coronary artery and a new bypass graft in the RCA was used for the administration of cardioplegic solution with no complications. There are various strategies for cardioplegic myocardial protection. The best method should be selected depending on the patient characteristics and condition.

Three Cases of Ascending Aorta-Abdominal Aorta Bypass for Atypical Coarctation with Takayasu's Aortitis / 日本心臓血管外科学会雑誌

We report 3 cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu's aortitis. We performed an extra-anatomical bypass from the ascending aorta to the terminal abdominal aorta. The graft was arranged to pass through the diaphragm from the pericardium, behind the left lobe of the liver and the stomach, to the front side of the pancreas to the terminal abdominal aorta. Although the graft was exposed in the abdominal cavity in part behind the stomach, it was completely covered with the great omentum thus avoiding direct contact between the graft the abdominal organs. Decrease in the pressure gradient between the ascending aorta and the abdominal aorta was achieved using a large prosthetic graft 14-16 mm in diameter. There are several advantages with this technique. (1) Positional change during surgery can be avoided. (2) Anastomosis can be performed in non-diseased vessels. (3) This bypass graft can be branched off to visceral arteries if necessary. Reduction of the after load on the left ventricle and long-term graft patency by using a large diameter prosthetic graft were anticipated. The postoperative courses of all cases were satisfactory. Case 1 died of another disease 11 years and 11 months postoperatively, but the graft to was still patent.

Change of Oxidative Stress in Cases of Cardiac and Aortic Surgeries / 日本心臓血管外科学会雑誌

We measured oxidative stress and antioxidative stress in clinical cases of cardiac and aortic surgery, especially in extracorporeal circulation cases. From June to October 2007, 18 cases who underwent cardiac and aortic surgery with extracorporeal circulation (ECC group) and 8 cases with an infra-renal abdominal aortic aneurysm (AAA group) were studied. We measured reactive oxygen metabolites (d-ROM) in oxidative stress for the operative time, after the operation endpoint, and at one day postoperatively, one, two, and three weeks postoperatively, and one, two, three, and four months postoperatively. Regarding d-ROM, the level in the ECC group was significantly higher than that in the AAA group (<i>p</i><0.0001). Peak values were observed 3 weeks postoperatively in the ECC group and 2 weeks postoperatively in the AAA group. Although the oxidative stress increased in both groups, the peak value in the ECC group was more marked than that in the AAA group. We concluded that oxidative stress under surgical stress in cardiovascular surgery with extracorporeal circulation was higher than that under surgical stress in cardiovascular surgery for infra-renal abdominal aortic aneurysms.

Long-Term Results of Patchplasty for True Thoracic Aortic Aneurysm and the Effectiveness of Open Stents in Recurring Cases / 日本心臓血管外科学会雑誌

We reviewed 24 cases of patchplasty for true thoracic aortic aneurysm performed in our hospital up to July 2001. The size of the aneurysm in the ascending aorta was 6.0cm (1 case), and the mean size in the aortic arch was 2.5±0.5cm (4 cases), that in the distal arch was 4.7±1.7cm (11 cases), and that in the descending aorta was 3.7±0.5cm (8 cases). The hospital mortality rate was 12.5% (3 patients out of 24). The causes of death were multiple organ failure, cerebral bleeding and sepsis. In the long-term results, 2 patients had recurrence, but there were no late deaths in relation to the aneurysmal recurrence. We performed open stent operations for severe adhesion and pulmonary dysfunction in the aneurysmal recurrence cases. The postoperative course of these cases was uneventful. The open stent was useful for the treatment of the aneurysmal recurrence in the distal arch.

A Case of Tumor-Like Thrombus in the Distal Aortic Arch / 日本心臓血管外科学会雑誌

We report a 65-year-old man with a mobile thrombus in the distal aortic arch with no previous history of thromboembolic events. There was no evidence of either aneurysmal changes or aortic dissection. Transesophageal echocardiography revealed the presence of a mobile tumor in the distal arch. The patient underwent elective resection. The mobile tumor was attached to the aortic wall, approximately 3cm distal to the left subclavian artery. Histological examination revealed an old thrombus containing calcification. He was discharged on the 22nd postoperative day with no thromboembolic complications. This is the first report of a case of mobile thrombus in the distal aortic arch in Japan.

A Case of Infected Type IIIb Aortic Dissection / 日本心臓血管外科学会雑誌

A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an <i>in situ</i> Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.

Operation for Acute Aortic Dissection 13 Years after Operation for Funnel Chest in Marfan Syndrome / 日本心臓血管外科学会雑誌

Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.

How Do Patients Think about Their Operation Scar after Cardiac Surgery? / 日本心臓血管外科学会雑誌

Because of the improved safety of cardiovascular surgical techniques, the small incision approach, called minimally invasive cardiac surgery (MICS), has recently been employed. In some cases of MICS, however, prolonged extracorporeal circulation time is required, and it is not minimally invasive in some aspects. It has been reported that the most prominent advantages of MICS is reducing the adverse consequences of conventional full-sternotomy, such as pain, bleeding and risk of mediastinitis, therefore it is helpful to reduce the period of hospitalization and costs. The small incision and cosmetic advantage is one of the objective advantages of MICS, so we interviewed 139 patients who underwent cardiac surgeries, to find out how they think of their operation scar. Most (61.9%) of the patients were not bothered by their scar, and the presence of keloid lesions mattered move than the size of their wound. What the patients considered to be most important were less pain after operation and shorter hospital stay, not to mention good results of the operation. The size and place of the wound ranked low in importance. It is important to be aware of the difference in thinking between the operative wound by patients and by the healthy medical staff. Furthermore it is important to recognize the difference between minimaly invasiveness and small incisions in cardiac surgery.

A Case of Mitral Valvuloplasty for Infective Endocarditis in a 22-Year-Old Woman / 日本心臓血管外科学会雑誌

A 22-year-old woman was admitted to our hospital with high fever and lumbar pain. Echocardiography revealed mitral regurgitation due to prolapse of the anterior mitral leaflet. On admission, her white blood cell count was high and results for C-reactive protein were positive. The blood culture was positive for hemolytic streptococcus. After the white blood cell count and C-reactive protein level were normalized, and the blood culture had become negative following treatment by multiple antibiotics, she underwent valvular surgery. Because the infectious lesion was limited to the mitral leaflet and chordae, mitral valvuloplasty was performed with a satisfactory postoperative result. The operative technique consisted of resection of the infected valvular tissue, implantation of artificial chordae with e-PTFE, and suture annuloplasty. To conclude, mitral valvuloplasty should be the operative method of choice in patients with infective endocarditis, especially in young women with the potential of future pregnancy and labor.

An Operation Case of Aortic Regurgitation and Pseudocoarctation of Aorta Associated with Takayasu's Aortitis / 日本心臓血管外科学会雑誌

A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

A Case Report of Coronary Artery Bypass Grafting without Cardiopulmonary Bypass for a Patient with Ischemic Severe Left Ventricular Dysfunction (LVFE 6 %) / 日本心臓血管外科学会雑誌

A 67-year-old man had ischemic cardiomyopathy. He had New York Heart Association class III heart failure with pleural effusion. Further examinations revealed an enlarged left ventricle with markedly reduced ejection fraction (6.2%) and 3-vessel coronary disease. He underwent single coronary bypass grafting, using the gastroepiploic artery (GEA) to RCA without cardiopulmonary bypass. He showed a remarkable improvement of cardiac function. He was discharged from our hospital (NYHA class I) on the 40th postoperative day and lives an almost normal life now. Coronary artery bypass grafting without cardiopulmonary bypass is one of the useful surgical techniques for patients with ischemic severe left ventricular dysfunction.

Surgical Treatment of Isolated Iliac Aneurysm. A Report of Three Cases / 日本心臓血管外科学会雑誌

Three cases of isolated iliac aneurysms were reported. The first case was a 28-year-old man who was transferred to our hospital in shock. The ruptured left iliac aneurysm was replaced with a prosthetic graft. It was assumed to be a rupture of a false aneurysm. The second case was a 60-year-old man who complained swelling of his right leg and dyspnea on exertion. Angiography revealed tht those symptoms were due to right iliac aneurysm with AV fistula. The aneurysm was replaced with a bifurcating graft and the AV fistula was closed concurrently. The third case was a 55-year-old man who had no symptoms. He had been followed up for hepatitis type C with periodical echogram. The echogram showed dilatation of his bilateral iliac arteries. On a diagnosis of bilateral iliac aneurysms, bifurcating graft replacement was performed. All of these three cases recovered successfully and were discharged. Because the greater part of the cases of isolated iliac aneurysms have few symptoms, many cases were first diagnosed through the event of its rupture. The number of cases of isolated iliac aneurysm with no symptoms will increase with advanced availability of abdominal echogram and CT scanning.

Axillo-femoral Bypass for Arteriosclerotic Occlusive Disease / 日本心臓血管外科学会雑誌

During a twelve-year period (1982-1993), 15 axillo-femoral bypass surgeries have been performed for aortoiliac occlusive disease. All patients were men, with an average age of 71.2 years. Axillo-bifemoral bypass was performed in 10 cases, and axillo-unifemoral bypass in 5 cases. In Additional femoro-popliteal bypass was required 3 cases. All cases had some accompanying disease, so they were considered to be high risk cases for anatomic bypass surgery. In the 12 elective cases, 2 hospital deaths (16.7%) occured due to the accompaning disease (atrial fibrillation and lung canser). At discharged leg symptoms had improved in 10 patients. In the long term postoperative phase, 4 patients died due to accompanying disease, and one was lost to follow up. Excluding these patients, the long term patency in the 5 surviving patients was 100%. In this series, we encountered a case of perigraft seroma, which is rare. The intractable perigraft seroma disappeared after the reoperation with another material graft. Axillo-femoral bypass is preferable for high risk patients with aortoiliac occlusive disease. In cases of severe respiratory dysfunction, it can be performed under epidural and local anesthesia.

A Case Report of Thoracoabdominal Aortic Aneurysm, with Occlusion of Celiac Artery Due to Mural Thrombus Formation / 日本心臓血管外科学会雑誌

Patient is a 58-year-old man who had a thoracoabdominal aortic aneurysm with abdominal angina due to the occlusion of celiac artery with mural thrombus in the aneurysm. He had a recurring abdominal pain for half a year, and relapsing elevation of serum transaminase levels. Graft displacement was performed, followed by reattachment of visceral vessels, celiac artery and superior mesenteric artery, using partial extracorporeal circulation. Abdominal angina due to thoracoabdominal aortic aneurysm has been seldom reported. It has been said that complete revascularization is not required as surgical therapy, and single vessel revascularization is sufficient to reduce symptoms. Preoperative angiography will reveal which vessels supply dominant blood flow to visceral organs, therefore, angiographic examination should be performed essentially prior to surgery.

Two cases of bilateral phrenic nerve paralysis following cardiac surgery / 日本心臓血管外科学会雑誌

Two cases of bilateral phrenic nerve paralysis were reported. The first case was a 51-year-old male who underwent mitral valve replacement for mitral valve regurgitation. Upon extubation he was noted to have the paradoxical breathing pattern associated with bilateral phrenic nerve paralysis. He was treated conservatively, keeping him in a sitting position without reintubation or tracheostomy. The patient recovered from the paradoxical breathing pattern by the tenth post-operative day. The second patient was a 66-year-old male who underwent mitral valve replacement and CABG for mitral valve regurgitation and angina pectoris. Upon extubation this patient was also noted to have a paradoxical breathing pattern. Conservative treatment was initiated. This patient suffered from sudden apneic episode followed by cardiac arrest on 17th post-operative day. Cardio-pulmonary resuscitation was successful, however, the patient was noted to have extensive ischemic brain damage after resuscitation. The patient died approximately one year later from respiratory failure. Generally speaking, the cause of phrenic nerve paralysis after cardiac surgery is cold injury from ice slush used for topical cardiac cooling. However, direct mechanical injury to the right phrenic nerve might result from the proximity of the right phrenic nerve to the left atrial suture line of a mitral valve replacement.