Ankylosing Spondylitis with Complete Atrioventricular Block and Aortic Regurgitation / 日本心臓血管外科学会雑誌

Ankylosing spondylitis is chronic, progressive, inflammatory disease involving the spine, peripheral joints, and periarticular structures. Cardiac abnormalities associated with ankylosing spondylitis are well recognized, but a case with DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for aortic regurgitation has not been previously reported. We report a case of a 66-year-old man with ankylosing spondylitis who was successfully treated by DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for severe aortic regurgitation.

Aorto-bilateral External Iliac Artery Bypass Graft in a Patient with Leriche Syndrome and an Ileal Conduit / 日本心臓血管外科学会雑誌

We report a patient with Leriche syndrome who had ileal conduit and a right lower quadrant stoma. A 47-year-old man with a history of bladder cancer had undergone radical total cystectomy with formation of an ileal conduit and right lower quadrant stoma 2 years previously. CT scanning revealed total occlusion of the distal aorta. He experienced right lower leg pain after 30 m of walking. Through a repeat midline laparotomy incision, the abdominal aorta was dissected with a transperitoneal approach. To avoid dissection around the ileal conduit, the retroperitoneum was incised (open) at the right of the ascending colon and at the left of the sigmoid colon. A prosthetic graft (Interguard 14×7 mm) was pulled bilaterally through these incisions, to the external iliac arteries. Abdominal aorto-bilateral external iliac artery bypass grafting was performed and the patient was discharged without complications on the 15th postoperative day.

Morphological Type and Histological Features of the Dilated Ascending Aorta in Patients with a Bicuspid Aortic Valve / 日本心臓血管外科学会雑誌

Bicuspid aortic valve (BAV) is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement (including coronary artery bypass grafting) from 2004 onwards, 60 (21.5%) with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta (≥45 mm) was the most common in the L/R type of BAV (48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.

Early Application of Continuous Hemodiafiltration (CHDF) after Open Heart Surgery on Hemodialysis Patients / 日本心臓血管外科学会雑誌

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, <i>n</i>=36) or hemodialysis (HD) (HD group, <i>n</i>=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, <i>p </i><0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, <i>p </i><0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

Postoperative Bleeding from the Right Lung after Aortic Root Replacement Treated Successfully with ECMO in a Patient Who Underwent Radical Operation for Tetralogy of Fallot 38 Years Ago / 日本心臓血管外科学会雑誌

We successfully performed aortic root replacement in an asymptomatic 52 year-old man with dilatation of the Valsalva sinuses (75 mm). The patient had previously undergone a radical operation for the tetralogy of Fallot at 13 years of age and AVR at 46 years of age. Massive bleeding occurred in the lungs after weaning from CPB. Emergency bronchoscopy revealed that the bleeding came from the right middle and lower lobes. The bleeding was stopped conservatively on POD 3 ; however, V-V ECMO was started on POD 5 because of severe hypoxia. ECMO was successfully weaned on POD 11 and he discharged on POD 59. The presence of developed bronchial collaterals and barotrauma during the operation were speculated the causes of the bleeding from the right lung.

Coronary Artery Bypass Grafting in Patients Aged 80 Years or Older / 日本心臓血管外科学会雑誌

Coronary artery bypass grafting (CABG) in elderly patients has been increasing in recent years. Between June 1981, and February 2004, 32 patients aged 80 years or older (mean 81.8) underwent CABG in our hospital. Twenty one patients (67%) were in New York Heart Association class III or IV. Incidence of emergency surgery in the elderly (17 of 32, 53%) was significantly (<i>p</i><0.0001) higher than that in younger patients (131 of 969, 13.5%). Total hospital deaths were 19% (6 of 32, emergency procedures 5, elective 1). The hospital deaths in patients with an ejection fraction (EF) of 45% or more (5 of 12, 42%) were significantly (<i>p</i><0.05) higher than those in patients with an EF of more than 45% (1 of 20, 5%). The main features of CABG in octogenarians was the high rate of emergency surgery and high mortality. Thus CABG in octogenarians should be performed early, before the cardiac function deteriorates, in order that treatment not be denied because of age alone.

Long-Term Results of Open Heart Surgery in Hemodialysis Patients-CABG vs. Valve Replacement- / 日本心臓血管外科学会雑誌

We evaluated 30 patients who required hemodialysis (HD) before open heart surgery between January 1990 and September 2003. The patients were divided into 2 groups according to surgical procedure: 20 patients underwent coronary artery bypass grafting (CABG group: 14 men and 6 women, mean age, 63 years), and 10 patients underwent valve replacement (VR group: 6 men and 4 women, mean age, 56 years). The mean duration of HD in the CABG group was significantly shorter than that in the VR group (67 months: 121 months, <i>p</i>=0.02). The actual survival rate was calculated by Kaplan-Meier's method. No patient was lost to follow-up. There were 3 hospital deaths in the CABG group (cerebral infarction, arrhythmia, and mediastinitis), and 2 hospital deaths in the VR group (gangrenous cholecystitis and sepsis). There were also 5 late deaths in the CABG group (acute subdural hematoma, pneumonia, AMI, heart failure and gastric cancer) and 4 deaths in the VR group (uterus cancer, 2 intracerebral hemorrhages and PVE). All cardiac event deaths in the CABG group had undergone CABG only with vein grafts. The 4-year actuarial survival rates were 56% (<i>n</i>=5) in the CABG group with a mean follow-up period of 29 months (max 156 months), and 47% (<i>n</i>=3) in the VR group with a mean follow-up period of 35 months (max 131 months). There are 3 points to improve the prognosis of open heart surgery in hemodialysis patients: control of postoperative infection in both groups, prevention of cardiac events in the CABG group and careful anticoagulation therapy in the VR group.

Long-Term Results of Abdominal Aortic Aneurysm Repair for Patients Aged over 90 Years / 日本心臓血管外科学会雑誌

Of 225 patients who underwent surgery for abdominal aortic aneurysm from April 1995 to June 2002, 8 patients. or 3.6%, aged 90 years or more (mean age 90.8±1.4. range 90 to 94, 7 men and 1 woman) were the subjects of this study. Four of these patients (50%) underwent emergency surgery. Of these 4 patients, preoperative shock was found in 1 patient. Preoperative complications were hypertension in 4 (50%), ischemic heart disease in 1 (13%), disseminated intravascular coagulation syndrome in 1 (13%), and pleuritis in 1 (13%). The maximum diameter of AAA was 69.5±16.6mm (range 48 to 100mm). The surgical procedure was median laparotomy. Long-term follow-up by the attending physician, or questionnaire by phone was completed for all patients and range to 6.3 years (median, 2.4 years). There were no hospital deaths. Postoperative complications were delirium in 2 (25%), atelectasis in 1 (13%), and ileus in 1 (13%). There were 5 (63%) late deaths. The causes of death were pneumonia in 2, senescence in 1, cardiac failure in 1, and rupture of a pseudoaneurysm at the anastmotic site in 1. Long-term survivals at 1 year, 2 years, and 3 years were 88±12%, 63±17%, and 20±18%, respectively, whereas expected survivals at 1, 2, and 3 years were 82%, 65%, and 51%, respectively. Longterm survivals were not good, but no significant difference was found between long-term and expected survivals. Therefore, this surgical and long-term treatment can achieve satisfactory results. This result led us to recommend performing the operation for patients aged 90 years or more, except if they were bedridden, had severe dementia, or were at the end stage of a malignant disease.

The Waffle Procedure for Postoperative Constrictive Epicarditis after Expanded Polytetrafluoroethylene Surgical Membrane as a Pericardial Substitute / 日本心臓血管外科学会雑誌

Several substitutes have been utilized for pericardial closure after open heart surgery. A 55-year-old man was admitted to our hospital with a diagnosis of constrictive pericarditis 13 years after open mitral commissurotomy. At reoperation, the thickened pericardium was peeled off and the epicardium was covered with 0.1mm expanded polytetrafluoroethylene surgical membrane (Gore-tex^®, sheet thickness 0.1mm). At the 7th postoperative day, he complained of fatigue and dyspnea. Physical examination revealed jugular venous distension, hepatomegaly, ascites and peripheral edema. Cardiac catheterization suggested the suspicion of pericardial or epicardial constriction. On the 3rd-operation, the Gore-tex^® sheet was removed and multiple longitudinal and transverse incisions were made in the thickened epicardium, that is the waffle procedure, while protecting the myocardium and the coronary arteries. Perioperative hemodynamics improved remarkably. His cardiac index increased from 3.0 to 4.5<i>l</i>/min/m². The postoperative course was uneventful.

Successful Conservative Treatment with Continuous Irrigation of an Electrolyzed Strong Acid Solution for Prosthetic Graft Infection of Abdominal Aorta / 日本心臓血管外科学会雑誌

A 65-year-old woman underwent abdominal aortic replacement using a woven Dacron tube graft for abdominal aortic aneurysm on April 2nd, 1996. She had pyrexia on the 6th postoperative day and abdominal enhanced CT scan showed periprosthetic bubble formations. She underwent relaparotomy 14 days after the initial procedure due to large retroperitoneal abcess bacterial culture of which revealed methicillin resistant <i>staphylococcus aureus</i>. She underwent debridement and local irrigation by an electrolyzed strong acid solution. Her pyrexia diminished immediately after relaparotomy and bacterial culture of the drain of the left retroperitoneal space became negative 82 days later. She was discharged and has had no active inflammatory signs for 3 years. She is doing well at present.

A Case of Simultaneous Surgical Treatment for Descending Thoracic Aortic Aneurysm, Coronary Artery Disease and Left Common Iliac Artery Stenosis under Partial Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

A 72-year-old woman underwent simultaneous combined surgical treatment for descending aortic aneurysm, coronary artery disease and left common iliac artery stenoses. The operation was performed through the left posterolateral thoracotomy via the 6th intercostal space and a left retroperitoneal approach. At first, 10mm woven Dacron graft was anastomosed to the abdominal aorta as an inlet of the cardiopulmonary bypass and the left femoral vein was used for venous drainage. A saphenous vein graft was anastomosed to the left anterior descending artery during partial cardiopulmonary bypass with the heart beating. Secondly, the aneurysm was replaced with 24mm woven Dacron graft. Thirdly, the proximal end of the vein graft was anastomosed to the Dacron graft of the descending aorta. Finally after cardiopulmonary bypass was terminated, the distal end of the woven Dacron graft for arterial perfusion was anastomosed to the left external iliac artery in end-to-side fashion. The postoperative course was uneventful. We conclude that simultaneous operation for descending aortic aneurysm and coronary artery bypass grafting through left thoracotomy with the heart beating is useful in these combined diseases.

Surgical Treatment for Cardiac Myxomas. 20 Years' Experience in Consecutive 17 Cases / 日本心臓血管外科学会雑誌

Between March 1976 and February 1996, 17 patients underwent surgical treatment for cardiac myxomas. There were 5 men and 12 women with a mean age of 55 years (range: 22 to 78 years). The location was the left atrium in 13, right atrium in 2, right ventricle in 1 and multiple locations in 1. Since 1978 the standard operative method to treat left atrial myxoma has been a biatrial approach with complete removal of cardiac myxoma and partial resection of the atrial septum. There were no perioperative deaths, but 1 patient had a permanent pace-maker implantation, 2 had transient atrial fibrillation during the early postoperative period, and 1 had acute pulmonary edema after resection of a right ventricular myxoma. There were two late deaths, not related to cardiac event and one recurrence with multiple myxomas. Overall with long term follow-up, the actual survival rate at 10 years was 75% (<i>n</i>=6), with a mean follow-up of 7.1 years, with a 100% follow-up ratio (17 patients). We conclude that the biatrial approach with complete removal of the left atrial myxomas and partial resection of the atrial septum is one of the best procedures for surgical treatment.

Open Heart Surgery for Steroid Treated Patients / 日本心臓血管外科学会雑誌

We evaluated 13 patients (4 men & 9 women, mean age: 61 years-old) who required steroid treatment for more than 1 month before open heart surgery. The subjects included 3 patients with collagen diseases, 3 with dermatopathy, 2 with bronchial asthma, one each with Takayasu's disease, autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, brain tumor and post-renal transplantation. Surgical procedures were performed with an AC bypass in 9 cases, one each with AVR, MVR, reMVR and ASD patch closure. The steroid treatment before open heart surgery had been continued for a mean of 4 years and 11 months at a mean dose of 9.4mg/day equivalent of prednisolone. We evaluated the adrenocortical function on the rapid ACTH test and found hypoadrenalism in 5 of 8 cases (63%). In these cases we gave either 100mg of hydrocortisone or 1, 000mg of methylprednisolone before open heart surgery. The total perioperative dosage of steroid was a mean of 2, 488mg equivalent of prednisolone, including 4mg/kg of betamethasone during the extra corporeal circulation. Postoperatively we lost one case due to ventricular rupture after MVR. Other major complications were seen in one case each, cardiac tamponade, temporary clamp, wound infection and lumbar vertebral fracture. For steroid treated patients, it is important to select the patient who really need steroid by the rapid ACTH test, and to use the minimum dosage of steroids in open heart surgery.

Aortic Arch Aneurysm Associated with Congenital Kinking of the Aorta / 日本心臓血管外科学会雑誌

A 31-year-old woman complained of dizziness. Preoperative aortogram revealed a saccular type of aneurysm of the aortic arch and abnormal origin of the left subclavian artery. She underwent reconstruction of the aortic arch through 4th intercostal thoracotomy on August 10th, 1996. The aneurysm originated distally to the left common carotid artery and its wall was very thin. Aortic arch replacement with woven Dacron prosthesis was performed between the left common carotid artery and the left subclavian artery using the inclusion method under hypothermic circulatory arrest. The post operative course was uneventful. Cystic medial necrosis of the aneurysmal wall, and normal arterial findings of the left femoral artery were recognized by the pathohistological examinations. Kinking of the aorta is a congenital disease due to abnormal embryonal development. The aortic arch elongates between the left common carotid artery and the left subclavian artery, and arch aneurysm originates in this portion, because the aneurysmal wall is very thin and fragile when accompanied with cystic medial necrosis. Therefore, it is important that the left subclavian artery originating distally to the arch aneurysm in this category of the aortic arch aneurysm be recognized. There are 11 cases which were successfully operated for aortic arch aneurysm associated with congenital kinking of the aorta in Japan.

A Rare Case of Primary Wireform Fracture Implanted in the Mitral Position of Carpentier-Edwards Pericardial Xenograft / 日本心臓血管外科学会雑誌

A 71-year-old woman underwent mitral valve replacement with Carpentier-Edwards Pericardial Xenograft for mitral regurgitation on January 8, 1987. She had nocturnal hematuria and paroxysmal nocturnal hemoglobinuria was diagnosed in November, 1992. She had congestive heart failure in February, 1993. Cineradiographical analysis revealed a fracture of the wireform in three locations of the Xenograft and the stent was distorted inward. A second mitral valve replacement was successfully performed on March 16, 1993. She was discharged 45 days after operation after an uneventful course.