Intravenous Infusion of Tranexamic Acid during Aortic Valve Replacement in a Patient with Indiopathic Thrombocytopenic Purpura / 日本心臓血管外科学会雑誌

An 82-year-old woman, who had suffered from idiopathic thrombocytopenic purpura (ITP) treated with oral steroids, was admitted to our hospital with worsening exertional dyspnea. Cardiac examinations revealed severe aortic stenosis with left ventricular dysfunction. High dose intravenous gammaglobulin therapy (400 mg/kg/day) for 5 days was conducted to increase the platelet count prior to the operation. However, a decrease was observed in the platelet count from 2.1×10⁴/mm³ on admission to 1.9×10⁴/mm³ before surgery. Without additional therapy, aortic valve replacement using a 19 mm bioprosthesis was performed with cardiopulmonary bypass (CPB). Tranexamic acid (20 mg/kg/h) was continuously infused from the skin incision to the end of the surgery. Forty units of the platelet concentrates were transfused just after weaning from CPB. The patient had no hemorrhagic complications. We believe that intraoperative administration of tranexamic acid combined with platelet transfusion is effective to reduce perioperative bleeding for a patient with ITP unresponsive to preoperative gammaglobulin therapy.

Mitral Valve Replacement for a Patient with Mirror-image Dextrocardia / 日本心臓血管外科学会雑誌

Dextrocardia is a rarely seen cardiac malposition in which the heart is pointed toward the right side of the chest. A 77-year-old woman was admitted to our hospital with exacerbated exertional dyspnea. Cardiac examinations revealed severe mitral regurgitation due to prolapse of the posterior mitral leaflet in mirror-image dextrocardia (situs inversus, L-loop ventricles, and inverted great arteries). Mitral valve replacement using a bioprosthesis and pulmonary vein orifice isolation were successfully performed. The operative view of the surgeon standing on the left side of the patient showed mirror-image dextrocardia represents left-right reversal compared with normal heart structure. This provided some challenges in establishing cardiopulmonary bypass and performing intracardiac maneuvers. The mitral valve was on the left side of the surgeon and different needle grips, different angle of suturing, and the choice of forehand or backhand suturing were required to obtain secure suturing in the mirror-imaged mitral annulus.

A Case of Acute Aortic Dissection Following Coronary Artery Bypass Grafting, Complicated with Upper Extremity and Bowel Ischemia / 日本心臓血管外科学会雑誌

A 65-year-old man had acute Stanford type A aortic dissection complicated with upper extremity paralysis, 7 months after coronary artery bypass grafting. The superior mesenteric artery (SMA) appeared patent on CT angiography. However, color Doppler ultrasonography revealed malperfusion of the SMA. Progressive metabolic acidosis indicated bowel ischemia. Although antihypertensive therapy was selected due to possible injury of the right internal thoracic artery (RITA) graft at thoracotomy, revascularization of the SMA and reconstruction of axillary arteries were indicated due to increased paralysis and acidosis. Following anastomosis of a saphenous vein graft between the iliac artery and the SMA, the color and movement of the small intestine apparently improved. The axillary artery was transected and reconstructed with fenestration. Metabolic acidosis improved after SMA bypass but before superior axillary artery reconstruction. Upper extremity paralysis improved. Seven days later, however, he complained of sudden onset of back pain associated with hypotension, which was due to cardiac tamponade. He underwent replacement of the ascending aorta, elevation of the aortic valve, and reimplantation of the radial artery graft. He had an uneventful postoperative course and was discharged with no remaining complaints. In this case, treatment of upper extremity and bowel ischemia was selected prior to central operation, and irreversible damage was avoided. Color Doppler ultrasonography was helpful for diagnosing bowel ischemia before progression to necrosis. It must be remembered that patency diagnosed with CT angiography does not necessarily rule out mesenteric ischemia.

Femoro-Femoral Bypass Anterior to the Pubis and Inside of the Thigh Muscle for Treatment of Suspected Infected Aneurysm in the Ilio-Femoral Area / 日本心臓血管外科学会雑誌

Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.

A Case of Redo Below-Knee Femoro-Popliteal Bypass Utilizing Segmental Patent Saphenous Vein Graft / 日本心臓血管外科学会雑誌

A 73-year-old man underwent initial below-knee femoro-popliteal bypass (FPBK) using an autologous saphenous vein graft (SVG). Six years later, a sudden leg pain developed in his right lower extremity and an emergency angiography disclosed total occlusion of the external iliac artery as well as SVG. Because sufficient arterial perfusion was not obtained even after emergent thrombectomy, redo FPBK was performed using a synthetic graft. For the distal anastomosis, we reused a segment of the previous patent SVG that had been still open at the distal anastomotic site. After cutting down the SVG at the non-thrombosed part, which was 1cm long from the distal anastomosis, 6mm ringed expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the stump in an end-to-end fashion. The proximal anastomosis was completed between the ePTFE graft and common femoral artery in an end-to-side fashion. The postoperative angiography demonstrated no stenosis of the distal anastomotic site and no occlusion of previous SVG. In a patient requiring redo FPBK, if previous SVG is not completely thrombosed at the distal anastomotic site, reutilizing the graft is one of the options to complete the redo operation in a safe and simple way. Because the long term patency of this type of composite graft has not been established, further careful observation is needed.

Surgical Treatment of a Case of Primary Angiosarcoma of the Right Atrium Associated with Cardiac Tamponade / 日本心臓血管外科学会雑誌

We report a case of angiosarcoma of the right atrium, which manifested as cardiac tamponade. A 50-year-old man was admitted to our hospital complaining of dyspnea on effort. Echocardiography and chest CT revealed massive pericardial effusion and a right atrial tumor mass. An emergency pericardiocentesis was performed to remove massive hemorrhagic fluids. Further examinations revealed primary cardiac neoplasm. Because there was no distant metastasis, the tumor in the right atrium was resected with the right atrial free wall under cardiopulmonary bypass support. The sinus node involved in the tumor was resected, necessitating pacemaker implantation. Microscopic examination of the resected tumor revealed angiosarcoma. As the resection border showed tumor tissue, postoperative radiotherapy was added. There was no evidence of recurrence or metastasis 14 months after surgery. The prognosis for angiosarcoma is very poor, and mean survival is less than 6 months. In cases with no metastases, early resection is the treatment of choice. In spite of incomplete resection, long-term survival may be possible with postoperative radiotherapy.