Improved Clinical Status Following Aortic Valve Replacement in Two Cases with Refractory Ascites Secondary to Aortic Stenosis and Insufficiency / 日本心臓血管外科学会雑誌

Ascites is a rare sign of aortic valve disease. Here, we report two cases of refractory ascites that had resulted from aortic stenosis and insufficiency and consequently improved after aortic valve replacement. The first case was a 44-year-old female who had undergone aortic valve repair for aortic stenosis 15 years earlier. She complained of dyspnea and severe abdominal distension due to unimproved massive ascites despite medical therapy. She was diagnosed with aortic stenosis and insufficiency and functional tricuspid insufficiency as well as complete atrioventricular block. She underwent mechanical aortic valve replacement, tricuspid annuloplasty and DDD pacemaker implantation. The second case was a 61-year-old man with a history of alcoholic liver disease who had been hospitalized for massive ascites, progressing rapidly in spite of aggressive medical therapy. Echocardiography revealed severe aortic stenosis and insufficiency; thus, he underwent bioprosthetic aortic valve replacement. Both patients were completely free from ascites about 6 months after surgery.

Successful Stentless Aortic Valve Replacement Navigated by VR Images in a Case of Bicuspid Aortic Stenosis with Valsalva Sinus Asymmetry / 日本心臓血管外科学会雑誌

SOLO SMART is a stentless bioprosthesis that comprises a larger effective orifice area and reduced pressure gradient, exhibiting a better hemodynamic profile than a stented bioprostheses. Currently, SOLO SMART finds application in patients with aortic valve diseases. However, patients with bicuspid aortic valve disease may present Valsalva sinus asymmetry. Recently, some studies have considered SOLO bioprosthesis as contraindicated in patients with a bicuspid aortic valve. Here, we report the case of a 79-year-old female with bicuspid aortic stenosis and Valsalva sinus asymmetry. We preoperatively assessed the aortic root of the patient using a novel 3D workstation that creates virtual reality (VR) images from cardiac CT data. After creating three symmetric commissures at the wall of the Valsalva sinus, we evaluated the distance from the coronary orifices. We determined the appropriate suture line of bioprosthesis avoid coronary orifice occlusion. Aortic valve replacement with SOLO SMART was successful, and the postoperative clinical course was uneventful. Hence, preoperative evaluation of the aortic root using VR images could be a precise and useful method for the assessment of the operative indication for SOLO SMART.

Unsuccessful LITA Harvest due to Sternocostoclavicular Hyperostosis / 日本心臓血管外科学会雑誌

A 78-year-old man presented at the emergency department with anterior chest pain. Coronary angiography (CAG) revealed three-vessel disease and percutaneous transluminal coronary angioplasty (PTCA) was performed on the right coronary artery. A preoperative plain chest computed tomography (CT) scan revealed hyperostosis of the sternum and clavicle. The patient underwent elective coronary artery bypass surgery 49 days later. During surgery, the thickness of the sternum caused difficulties with implementing median sternotomy. The pleura was also thicker than usual and even pulsation of the left internal thoracic artery (LITA) could not be determined due to severe adhesion. We harvested the right internal thoracic artery (RITA) instead of the LITA. The RITA was in a similar condition, but a 5 cm proximal portion could be prepared. The saphenous vein graft was anastomosed to the left anterior descending coronary artery after proximal anastomosis to the ascending aorta with the heartstring device because of the calcified aorta. The RITA-saphenous vein composite graft was anastomosed sequentially to the distal right coronary and circumflex artery. The patient's postoperative course was uneventful but he complained of numbness and lassitude of both upper extremities for one month. A postoperative contrast-enhanced CT scan revealed a patent LITA surrounded by thick tissue, indicating inflammatory disorders. The CT findings indicated a diagnosis of sternocostoclavicular hyperostosis. The postoperative CAG findings indicated that all bypass grafts were patent and the patient was discharged 32 days after surgery. Sternocostoclavicular hyperostosis is an inflammatory disease that might require surgeons to carefully reconsider graft selection.

Coarctation of the Aorta in an Adult Diagnosed by the Presence of Complete AV Block and Heart Failure / 日本心臓血管外科学会雑誌

A 51-year-old woman, who had been undergoing regular treatment and follow-up for hypertension since the age of 17, was diagnosed to have a patent ductus arteriosus (PDA) 6 months previously. On experiencing dyspnea, she visited the emergency room, where she was found to have a complete Atrioventricular (AV) Block and therefore was immediately admitted. The next day, she experienced acute heart failure requiring intubation. A DDD pacemaker was then implanted and the patient recovered thereafter. After recovery, a screening contrast-enhanced CT scan revealed coarctation of the thoracic aorta. The arterial pressure gradient between the arms and legs was about 70mmHg. The division of the PDA and the replacement of the coarcted aortic segment were performed under femoro-femoral cardiopulmonary bypass through a left posterolateral thoracotomy. The patient's postoperative course was good, however, she complained of abdominal pain on the 6th postoperative day. An abdominal CT scan showed hemorrhage in the left rectus abdominus and right iliopsoas muscles. This improved after rest. No arterial pressure gradient was observed between the arms and the legs postoperatively. She was discharged on postoperative day 20.Because the average life expectancy of patients with untreated coarctation of the aorta has been reported to be about 34 years, it is recommended that surgical repair be performed as soon as possible. Patients with childhood-onset hypertension should therefore be evaluated to determine the primary disease whenever possible, such as coarctation of the aorta as in this case.

A Case of Acute Occlusion of the Brachial Artery due to Strangulation and Traction / 日本心臓血管外科学会雑誌

A 61-year-old woman with paresthesia and coldness of the right forearm came to our institute. Her right arm was strangulated and tracted by a vinyl string tied at her right brachium. No pulsation of her right radial artery was detected, and her forearm had swollen with subcutaneous hematoma. Her arteriography showed occlusion of the distal site of the right brachial artery, and just proximal to the brachial arterial bifurcation was enhanced by collaterals. She underwent emergency revascularization 6h after injury. There was a thrombus in the artery at the strangulated site, and the arterial intima was circumferentially dissected. The injured site of the artery was completely resected and interposed with basilic vein. Although 8h had passed from injury to reperfusion, myonephropathic metabolic syndrome did not occur after the operation. Her brachial arterial pulsation is now well palpable. The arterial occlusion was probably caused by the circumferential tear of the intima due to not only direct strangulation but also strong traction of the arm. It is necessary to resect a sufficient length of injured artery.