A Case of Disseminated Intravascular Coagulation Complicating Thoracic Aortic Aneurysm for Which Recombinant Human Soluble Thrombomodulin Was Effective / 日本心臓血管外科学会雑誌

Chronic disseminated intravascular coagulation (DIC) complicates 5.7% of thoracic aortic aneurysm. DIC with thoracic aortic aneurysm is characterized by hyperfibrinolysis, but usually shows a stable condition in a state of compensated non-overt DIC with limited hemorrhagic symptoms. However, in some cases, hemorrhage caused by external factors may induce uncompensated overt DIC and lead to serious hemorrhagic tendencies. In the present study, we report a patient with a thoracic aortic aneurysm complicated by DIC who exhibited marked hemorrhagic tendencies. DIC remarkably improved following administration of recombinant human soluble thrombomodulin.

Successful Repair of Critical Anastomotic Bleeding after Surgery for Ruptured Infected Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

Infected aortic aneurysm is very difficult to treat and is associated with a high mortality rate. A 78-year-old man had been scheduled to undergo selective endovascular repair for distal aortic arch aneurysm. While standby, however, he was admitted to our emergency room because of hemoptysis. Rapid dilatation of the aneurysm shown on serial CT and elevated of inflammatory reactions yielded a diagnosis of infected aortic aneurysm. Because the aneurysm had ruptured into the left lung, emergency surgery was performed. Six days after the first operation, critical bleeding due to anastomotic disruption of the distal aorta caused by infection and subsequent cardiac arrest occurred. We immediately started open chest massage and controlled the bleeding manually in the ICU, while an operating room was prepared. In the redo operation, anastomotic disruption was repaired using the visceral pleura under deep hypothermic circulatory arrest. Anastomotic bleeding is a potentially life-threatening condition, therefore extremely prompt measures are vital. Appropriate management based on the assumption of anastomotic bleeding was very important in the postoperative course of this case of infectious aortic aneurysm.

Serial Angiographic Evaluation Over 5 Years after Coronary Bypass Surgery / 日本心臓血管外科学会雑誌

This study was designed to evaluate the late changes of coronary bypass grafts in 60 patients who had undergone coronary bypass surgery and postoperative angiography in the period from 1994 to 1999. Angiography was performed at mean intervals of 84 months and a total of 134 grafts and 162 anastomoses were visualized. The Left internal thoracic artery and saphenous vein had a patency of 85% and 82%, there was not statistically significant. In this series, late graft function did not relate to the site of implantation, that was mainly due to excellent results of saphenous vein grafts. With increasing proximal stenosis severity (under 75% versus over 90%), there was an increase in patency rates and this relationship was statistically significant (<i>p</i>=0.0005). That was why about 20% of the grafts to moderately stenotic target vessels had occluded within 1 month after surgery. Ten patients among these 60 had cardiac symptoms, 6 were due to graft failure and the other 4 were due to new lesions in the right coronary artery. In the other 12 patients new coronary artery lesions without cardiac symptoms had been detected. Periodic coronary examinations should be recommended for the patients after surgery, regardless of the absence of symptoms.

A Case of Marfan's Syndrome with Acute Aortic Dissection during Pregnancy / 日本心臓血管外科学会雑誌

We present a case of Marfan's syndrome with acute aortic dissection during the trimester of her pregnancy, who underwent a Bentall operation 2 days after emergency cesarean section. A 24-year-old woman during the 31st week of pregnancy visited our emergency room due to sudden onset of chest and back pain, though she had no abnormality until this event. Because of her tall height, spider fingers, positive wrist sign, visual disorder and scoliosis, she was given a diagnosis of Marfan's syndrome. Enhanced CT and cardiac ultrasonography revealed that she was suffering from acute aortic dissection with annulo-aortic ectasia. Since it was difficult for her to continue with her pregnancy, she underwent emergency cesarean section and gave birth to a male baby weighted 1, 706g. Although there was little likelifood of early thrombus formation in the false lumen or significant aortic regurgitation indicating an emergency operation, fear of massive bleeding from her uterus and the exfoliated surface of the placenta after cesarean section required an observation period of 2 days. We performed a Bentall operation successfully after careful sedation, ventilation and blood pressure control for 2 days.

Successful Conversion of Atriopulmonary Anastomosis to Total Cavopulmonary Connection Using Autologous Atrial Flap / 日本心臓血管外科学会雑誌

We report a successful conversion of atriopulmonary anastomosis to total cavopulmonary connection using an autologous atrial flap. A 28-year-old man after atriopulmonary anastomosis with a valve conduit performed under a diagnosis of double inlet left ventricle (DILV), d-TGA, was admitted with moderate cyanosis and atrial fibliration which he had suffered since age 25. Cardiac catheterization and ultrasonic cardiography revealed regurgitation at the site of tricuspid patch closure, and atrial dilatation. We excised the regurgitated patch, closed tricuspid valve leaflets, and made an atrial lateral tunnel using an autologous atrial flap. In particular we took care of crista terminalis, sinus node arteries, and sinus node at the operation. He recovered his sinus rhythm on the first operative day, but secondary atrial fibrillation developed. Four months later, catheterization showed good hemodynamics with low central venous pressure, and no obstruction of the atrial tunnel.

Postoperative Aortic Regurgitation Probably due to Use of Gelatin-Resorcin-Formalin Glue for Acute Aortic Dissection / 日本心臓血管外科学会雑誌

A 45-year-old man presented with cough and dyspnea. He had undergone reconstruction of the ascending aorta for acute aortic dissection (DeBakey type I) 5 months previously, at which time we used the gelatin-resorcin-formalin glue (GRF glue) for reconstruction of the wall layer. Preoperative transesophageal echocardiography and aortography revealed aortic regurgitation due to redissection of the aortic root. Intraoperatively, dehiscence was noted between the right coronary sinus including the coronary ostia and the non-coronary sinus. These intraoperative findings suggested that the pathology leading to the redissection was related to the previous use of GRF glue. The redissected segment appeared to be necrotic on macroscopic examination intraoperatively, however histological examination revealed only degenerative changes, and there was no evidence of the glue. He was treated by the modified Bentall method and had a good postoperative course after discharge. In this case, it is also conceivable that tissue necrosis resulted from the use of too much formalin.