Ruptured Coronary Aneurysm with a Congenital Coronary Arteriovenous Fistula / 日本心臓血管外科学会雑誌

An 83-year-old man was transferred to our hospital with cardiac tamponade and suspected cardiac tumor detected by enhanced CT. Coronary angiography showed a coronary aneurysm of 50 mm ID on the left circumflex artery. An emergency surgery was performed to excise the aneurysm, and a fresh thrombus occupying the efferent artery was observed. Both the afferent and efferent vessels were closed by suture. The patient made an otherwise uneventful recovery. This case featured a fresh red thrombus formed in fistulous outflow of the coronary aneurysm that seemed a direct cause of rupture.

Simplified Negative Pressure Wound Therapy for Pediatric Mediastinitis after Cardiac Surgery / 日本心臓血管外科学会雑誌

<b>Objectives</b> : Mediastinitis results in significant morbidity in pediatric patients after cardiac surgery. The management of mediastinitis is not well established in the pediatric population. Our strategy for pediatric mediastinitis after cardiac surgery consists of rapid introduction of simple vacuum-assisted drainage system and sternal closure without plombage under aseptic conditions. The efficacy of our strategy was examined. <b>Methods</b> : The records of 7 pediatric patients with mediastinitis after cardiac surgery managed with this drainage system from May 2006 to May 2013 were retrospectively reviewed. The median age of the patients was 20.5 months and median body weight was 9.7 kg. Mediastinitis occurred 1-3 weeks after surgery. The mediastinum was re-explored immediately under general anesthesia after the diagnosis was made, and continuous drainage was used after extensive debridement was performed. We developed a simple vacuum-assisted drainage system consisting of conventional polyurethane foam, surgical drape containing povidone-iodine, and 1 to 3 silicone drainage tubes connected to a drain aspirator (-99 cmH₂O). Patients were allowed oral intake and resumption of daily activity after extubation. The components of the drainage system were exchanged every 2-3 days. The sternum was closed without the use of the omentum or muscle for plombage of the mediastinum after two negative topical swab cultures were obtained. <b>Results</b> : Negative topical swab cultures were obtained in all cases (3-12 days after the drainage commencement) and the sternum was closed 7-19 days after the drainage commencement. The median duration of hospital stay was 31 days (range, 14-47). Although one patient with prenatal infection died of aortic rupture, the remaining six children survived and did not experience recurrence after hospital discharge. <b>Conclusion</b> : The simple vacuum-assisted drainage system enabled rapid control of wound bacterial infection and sternal closure in postoperative pediatric mediastinitis without the need for special, and expensive devices.

An Aortic Arch Aneurysm Developing Late after a Non-anatomical Bypass Surgery for an Aortic Coarctation in Adulthood / 日本心臓血管外科学会雑誌

A 48-year-old man underwent an non-anatomical bypass surgery for aortic coarctation when he was 38 years old, when a bypass laid between the left subclavian artery and the descending aorta with a prosthesis (10 mm, internal diameter). Four years after the first surgery, aortic aneurysms at the proximal and distal sites of the coarctation were detected. Six years from then, we decided to perform another surgery when the maximum diameters of the proximal and distal sites exceeded 60 and 47 mm, respectively. We performed the aortic replacement from the proximal left subclavian artery to the descending aorta at eighth thoracic vertebra. The approach to the aortic aneurysm was through the extended left thoracotomy with the transection of the sternum. The cardiopulmonary bypass was established with an antegrade aortic perfusion (from the ascending aorta) and drainage from the right atrium. The circulatory arrest was obtained under deep hypothermia at 20°C measured by deep body temperature. After the surgery, the pressure differences between upper and lower extremities decreased to 10 mmHg, which had been 40 mmHg before surgery. Macroscopic observation showed the coarctation site was completely obstructed by an old thrombus. From this observation, we surmise that one of the reasons for the aneurysmal formation at the proximal site of coarctation might be an insufficient depressurization by the non-anatomical bypass grafting from the left subclavian artery to the descending aorta at the first surgery. We consider that a severe coarctation might become thrombotic sooner or later after a non-anatomical bypass surgery due to a change of blood flow, and a radical anatomical surgery would be recommended for adult coarctation cases.

Successful Repair of Tricuspid Valve Endocarditis in a Drug Abuser / 日本心臓血管外科学会雑誌

This case report describes a 20-year-old man, who was a drug abuser, and was treated surgically for tricuspid valve endocarditis. He presented with fever, caused by tricuspid valve endocarditis with a lung abscess. Blood culture detected <i>Staphylococcus aureus </i>and cardiac ultrasonography showed tricuspid insufficiency and tricuspid valve vegetation. He was treated with intravenous antibacterial agents, but the inflammation signs did not improve. He had a large number of puncture scars, as a consequence of self-injection of drugs in his lower arm. He underwent tricuspid valve plasty, and recovered successfully. He was discharged 2 weeks after surgery, and we instructed him to return for follow-up examination in our hospital. However, he did not return to our hospital because he was arrested for drug possession. In such cases, it is necessary to consider the operative method relative to reuse of drugs in the postoperative management of medication.

Two Cases of Pseudoaneurysms in Multiple Anastomotic Sites Occurring after the Original Bentall and Cabrol Procedure / 日本心臓血管外科学会雑誌

We report two cases of pseudoaneurysms occurring at the anastomotic sites that had to be repaired several times after the original Bentall and Cabrol procedure. Case 1. A 62-year-old man had surgery to repair pseudoaneurysms at the anastomotic sites of the distal ascending aorta and right coronary artery 22 years after undergoing the original Bentall procedure. The anastomosis of the left coronary artery was normal at the time of the operation ; however, he was given a diagnosis of a pseudoaneurysm at the anastomotic site of the left coronary artery 2 years after the operation. Case 2. A 61-year-old man with Marfan syndrome underwent surgery twice to repair pseudoaneurysms at the anastomotic sites of the aortic annulus and the left coronary artery 2 and 11 years, respectively, after the original Cabrol procedure. In addition, 23 years after the Cabrol procedure, he was given a diagnosis of a pseudoaneurysm at the anastomotic site of the distal ascending aorta. Their pseudoaneurysms were successfully treated by the reanastomosis of new grafts. Computed tomography detected no recurrence of the pseudoaneurysm in the follow-up period. However, continual close observation for the recurrence of a pseudoaneurysm in the remaining anastomotic sites is necessary.

Surgical Treatment for Kommerell Diverticulm / 日本心臓血管外科学会雑誌

We report 3 surgical cases of aortic graft replacement with reconstruction of an aberrant subclavian artery (ASA) for Kommerell diverticulum (KD) and ASA. Cases 1 and 2 both had a right aortic arch, KD and a left ASA. In these 2 cases, we performed distal aortic arch replacement and <i>in-situ </i>reconstruction of the left ASA via a right thoracotomy. Case 3 had an aortic arch aneurysm, KD and a right ASA. In this patient, we chose median sternotomy and total aortic arch replacement, using 2 pieces of artificial grafts with 1 and 4 branches, respectively. The right ASA was reconstructed by end-to-side anastomosis between the right axillary artery and the side branch of the graft with 1 branch. In all 3 cases, cardiopulmonary bypass and deep hypothermia with a rectal temperature under 18°C were used in aortic graft replacement. In addition to deep hypothermia, either antegrade or retrograde cerebral perfusion was introduced, depending on the surgical situation, to provide additional brain protection. Selective ASA perfusion was performed in all patients during aortic graft replacement. In Case 1, aortic anastomosis was achieved while clamping, and cerebral perfusion was maintained via a cannula for aortic return at the ascending aorta. In Cases 2 and 3, aortic anastomosis was performed under deep hypothermic circulatory arrest, using retrograde and antegrade cerebral perfusion respectively in Cases 2 and 3. The postoperative course was uneventful in all 3 patients.

Successful Operation for Multiple Giant Aneurysms with Congenital Coronary Artery Fistula in an Adult / 日本心臓血管外科学会雑誌

We report a case of successful operation for multiple giant aneurysms with a right coronary artery fistula from the right coronary artery to the left atrium. A 35-years-old woman was found to have a right coronary artery aneurysm with a maximum diameter of 85mm, and two other coronary artery aneurysms with maximum diameters of 40 mm along the coronary fistula, which arose from the proximal right coronary artery, traversed the root of the left atrium, and drained into the left atrium. Surgical treatment was indicated to relieve symptoms and to prevent possible rupture of the aneurysms. She underwent resection of coronary artery aneurysms, closure of orifices of the fistula and coronary bypass grafting to the right coronary artery with cardiopulmonary bypass. Her postoperative course was uneventful, and she was discharged in good condition.

Aortic Sepsis with Aorto-Pulmonary Fistula Following Infective Endocarditis (IE) / 日本心臓血管外科学会雑誌

A 59-year-old man presented with sporadic febrile illness. Echocardiography showed multiple vegetations on the mitral valve. Blood culture yielded <i>Viridans streptococci</i>. Mitral valve replacement was performed, and a high dose of penicillin G sodium (24 million U/day) was administrated for 4 weeks postoperatively. On the 28th postoperative day, the patient developed severe back pain and bloody sputum. Chest CT showed a false aneurysm of the distal aortic arch (5.5cm). The patient was placed on cardiopulmonary bypass with the arterial return in the mid-aortic arch. The aneurysm was resected and replaced with a Dacron tube during deep hypothermic circulatory arrest. The aortic wall was interspersed with mobile nodules that appeared to be colonized. The aorto-pulmonary fistula was directly closed. The whole procedure was carried out through the 4th intercostal space. The tissue culture was negative but histopathology suggested a persistent inflammatory process. Excavating aortic sepsis may occur following active endocarditis. Even if cardiac infection is controlled, continuous search should be undertaken for possible dilatation in remote parts of the arterial system.