Ventricular Septal Perforation Repair Carried out on a Jehovah's Witness / 日本心臓血管外科学会雑誌

In a 63-year-old male patient Jehovah's witness, IABP was introduced due to acute myocardial infarction and cardiogenic shock, and PCI (BMS) was carried out to CAG #7 100%. Stent placement was carried out and his hemodynamics stabilized. A left-to-right shunt was observed upon carrying out LVG, so the patient was referred to our hospital for surgery purposes due to a diagnosis of ventricular septal perforation (VSP). Upon transferring the patient to hospital, his PA pressure elevated to 53 mmHg although the blood pressure was maintained, and no findings of right heart failure were observed. His respiratory condition was stable. Emergency surgery was considered, but the patient was taking Clopidogrel following PCI, and so VSP repair (extended endocardial repair) was carried out following 4 days discontinuation of Clopidogrel. Preoperative anemia was not observed ; however, postoperative hemorrhagic anemia improved due to iron preparation administration, and the patient was discharged from hospital 22 days following surgery without blood transfusion.

Two Cases of Quadricuspid Aortic Valve with Aortic Regurgitation / 日本心臓血管外科学会雑誌

Congenital quadricuspid aortic valve is a very rare malformation. We report two cases with severe aortic regurgitation due to isolated quadricuspid aortic valve. It consisted of three equal cusps and one smaller cusp, which was identified at the time of valve replacement surgery for severe aortic regurgitation.

Successful Repair of Critical Air Leakage after Surgery for a Large Thoracoabdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 76-year-old woman with a sudden onset of chest and back pain was admitted to our hospital. Computed tomography (CT) showed a giant thoracoabdominal aortic aneurysm. Therefore, the patient underwent emergency operation. Under a left anterolateral thoracotomy and pararectal laparotomy with left heart bypass, we performed graft replacement of the thoracoabdominal aorta and reconstruction of the celiac artery, superior mesenteric artery and renal arteries. The left lung was tightly adhered to the aneurysm because of the contained rupture. Copious pulmonary bleeding and air leakage occurred due to thrombectomy of the aneurysm. During the operation, critical air leakage was repaired using the remaining aneurysmal wall. The postoperative course was uneventful. The patient was discharged 16 days after surgery. Copious air leakage due to lung injury was a potentially life-threating condition in the postoperative course of this case of thoracoabdominal aortic aneurysm. Surgical treatment of critical air leakage due to lung injury is very important in thoracic surgery.

Trans-Thoracic Aortic Insertion of Intra-Aortic Balloon Pumping for the Patient of Ischemic Cardiomyopathy with Severe Arteriosclerotic Disease / 日本心臓血管外科学会雑誌

A 58-year-old man with diabetic nephropathy had been on hemodialysis for 15 years. He had lost his left leg below the knee and whole right leg due to atherosclerotic necrosis. During the past 3 years, his cardiac function had also gradually deteriorated. For the past 2 years, echocardiography showed progressively worsening mitral valve regurgitation. Coronary angiography showed severe stenosis in the left main trunk and left descending artery. Ischemic cardiomyopathy with mitral regurgitation were diagnosed. He underwent coronary artery bypass grafting and mitral valve annuloplasty. Because of difficulty in weaning him from cardiopulmonary bypass, he required intra-aortic balloon-pump (IABP) support. An IABP was inserted through the ascending aorta via a tube graft. It was removed on the 4th postoperative day with a small skin incision, under local anesthesia. The postoperative course was uneventful. This IABP insertion technique was useful for a patient with severe arteriosclerotic disease.

Tranexamic Acid Reduces Bleeding during Off-Pump Coronary Artery Bypass Grafting in a Patient on Clopidogrel / 日本心臓血管外科学会雑誌

A 72-year-old man was admitted to a local hospital with symptoms of unstable angina pectoris. He was given Clopidogrel for acute coronary syndrome. Coronary angiography showed left main trunk and three-vessel disease. He was then admitted to our hospital due to a sudden onset of unstable angina following shock during the PCI procedure. We performed emergency off-pump coronary artery bypass grafting (OPCAB). He received 10 mg/kg/h tranexamic acid during the operation. He also received 2,000 U ascorbic acid at the start of surgery and 2,000 U after undergoing anastomoses of the coronary artery. Postoperatively, only some minor bleeding was observed. Tranexamic acid and Ascorbic acid reduce bleeding, and transfusion requirements of packed red blood cells, platelets, and the total blood units in patients on Clopidogrel who undergo emergency OPCAB.

Successful Off-Pump Coronary Artery Bypass Grafting for a Renal Transplant Patient / 日本心臓血管外科学会雑誌

This paper reports the findings of off-pump coronary artery bypass grafting (OPCAB) for a 56-year-old man who had undergone a renal transplantation. Coronary angiography (CAG) revealed triple-vessel coronary disease. OPCAB was therefore performed. The patient was discharged 20 days after surgery without any subsequent rejection, infection or renal dysfunction. At two years after the operation the patient is doing well without any cardiac events. Cardiac disease, especially coronary artery disease is a common cause of death in renal transplant patients. Cardiac surgery in renal transplant patients is expected to increase. OPCAB for renal transplant patients with ischemic heart disease is therefore expected to reduce the incidence of myocardial infarction, thereby prolonging patient survival.

Coronary Artery Bypass Grafting in Cases of Calcified Ascending Aorta / 日本心臓血管外科学会雑誌

The authors employed a modified CABG procedure to avoid cerebral infarction in cases of calcified ascending aorta. Among 348 cases of CABG surgery, we used the modified procedure in 14 cases (4%). The mean age was 66. Four patients had a history of previous stroke and one patient had arteriosclerosis obliterans. Our strategy is, (1) use femoral or aortic arch cannulation for cardiopulmonary bypass (CPB), (2) maximal use of <i>in-situ</i> arterial graft, (3) graft-coronary anastomosis under ventricular fibrillation (Vf) without aortic cross clamp, (4) proximal anastomosis of saphenous vein graft (SV), if used, was made at the arterial graft, otherwise direct anastomosis to the aorta was made under circulatory arrest. The internal thoracic artery (ITA) was used in 18 cases and the gastroepiploic artery (GEA) was used in 8 cases, SV was used in 4 cases. The mean Vf time was 48min and mean CPB time was 94min. The peak CPK was 805U and the peak CPK-MB was 52U. There was no significant difference between modified and conventional procedures in terms of operation time and myocardial protection. No cerebrovascular complication was noted with the modified procedure. In conclusion, the modified technique is safe for atherosclerotic-ascending aorta in CABG.

Left Ventricular Rupture after Mitral Valve Replacement / 日本心臓血管外科学会雑誌

We studied possible factors to cause left ventricular rupture after mitral valve replacement and the prevention in eight patients of 1, 046 receiving mitral valve replacement between September, 1965 and August, 1991. The age at operation ranged from 43 to 67 years old (average 58 years old), and there were one man and seven women. According to the Treasure and Miller's classification, the type of rupture was type I in 5, type II in 2, and type III in 3. The onset time of rupture was immediately after cardiopulmonary bypass in 3 and at the time of chest closure in one. In four patients it occurred 11 hours, 14 hours, 18 hours and 25 hours after operation, respectively. In 8 patients, repair was performed with external closure under heart beating and in five patients with both internal and external closure during cardiac arrest under cardiopulmonary bypass. Two patients under cardiopulmonary bypass were successful for hemostasis, however, they died with low cardiac output syndrome, following to multiple organ failure 2 or 44 days after operation, respectively. The repair was not successful in 6 patients. In four patients the left ventricular rupture occurred immediately after hypertension and pathological findings showed severe myocardial degeneration of left ventricular muscle in all of them. These findings may suggest that hypertension after the operation is one of major factors to cause left ventricular rupture and thus the careful management of the systemic blood pressure after mitral valve replacement is effective to prevent the left ventricular rupture.