Left Ventricular Free Wall Rupture Long-Term Development after Aortic Valve Replacement / 日本心臓血管外科学会雑誌

In 1984, a 67-year-old man had aortic valve replacement surgery for aortic regurgitation; he returned with chest pain on May 15, 2003. Emergency coronary angiography was performed because electrocardiogram revealed ST segment depression in leads V₄ to V₆. However, coronary angiography, echocardiogram and chest computed tomography finding were normal. Therefore the patient was discharged the following day. However, he was re-admitted for chest pain, followed by loss of consciousness 4 days after his initial release. Echocardiogram and chest computed tomography revealed perforation in the lateral wall of his left ventricle (LV) and a “blow-out” type rupture was diagnosed. The patient fell into cardiogenetic shock in the emergency room, and emergency left ventricular free wall rupture (LVFWR) surgical repair was performed under percutaneous cardiopulmonary support (PCPS). A round perforation measuring about 10mm in diameter was observed in the lateral LV wall along the course of LCx # 12. The perforation was closed using Teflon strip reinforced mattress sutures. The hemostasis was reinforced with fibrin glue sheet (TachoComb) and polyglygolic acid surgical mesh (Dexon Mesh), with fibrin glue extensively applied. He was discharged on July 17, 2003 without major complications. In this case, the precise cause that led to LVFWR was unknown. Emergency PCPS insertion enabled the LVFWR surgical repair and extensive adhesion due to the previous AVR prevented the massive bleeding to pericardial cavity and the catastrophic hemodynamic deterioration: both factors positively contributed to patient recovery.

A Case Report of Dor's Operation for Left Ventricular Aneurysm with Cardiac Failure 19 Years after the Operation for Post Infarction Ventricular Septal Perforation / 日本心臓血管外科学会雑誌

We encountered a case of Dor's operation for left ventricular aneurysm with cardiac failure 19 years after operation for post-infarction ventricular septal perforation. A 70-year-old man, who had undergone patch closure for ventricular septum perforation due to acute anteroseptal myocardial infarction, was admitted for congestive heart failure. Preoperative left ventriculography (LVG) revealed large anteroseptal and ventricular septal aneurysm. The left ventricular ejection fraction (LVEF) was 39%, and the left ventricular end diastolic volume (LVEDV) was 200ml. Dor's operation and coronary artery bypass grafting to the left circumflex branch was performed. The postoperative course was uneventful and the patient was discharged 33 days after the operation. Postoperative LVG revealed improved left ventricular function and showed that LVEF was 45% and LVEDV was 171ml. The large akinetic aneurysm was formed 19 years after operation following the linear closure method. LVG after Dor's operation showed remarkable improvement for left ventricular function. These findings indicated that Dor's operation is superior to the linear method.

Myonephropathic Metabolic Syndrome after Cardiac or Aortic Surgery / 日本心臓血管外科学会雑誌

Myonephropathic metabolic syndrome (MNMS) is a fatal complication following open-heart or aortic surgery. We evaluated 7 cases of MNMS following cardiac or aortic surgery. The patient's ages ranged from 43 to 81 years old. Of the 7 patients, four presented with myocardial infarction, which required coronary artery bypass grafting (CABG), and three presented with acute aortic dissection. Two patients with Stanford type A underwent total arch replacement and CABG and 1 patient with Stanford type B underwent a left axillo-femoral bypass. MNMS was caused by acute arterial occlusion due to intra-aortic balloon pumping (IABP) or percutaneous cardio-pulmonary support (PCPS) in patients who experienced myocardial infarction and acute lower limb ischemia in patients who experienced aortic dissection. The ratio of MNMS caused by IABP and PCPS, and acute aortic dissection was 1.4% and 4.2%, respectively. Four patients died; 3 had undergone CABG and 1 had undergone an aortic operation 18.5h after acute dissection. Both IABP and PCPS were removed early in possible cases. Limb wash-out was performed in 1 patient, and 5 were treated with hemodiafiltration. IABP and PCPS should be introduced via a prosthetic graft if limb ischemia is noticed. MNMS should be recognized as a disastrous complication of aortic dissection, and early bypass graft or limb amputation may become the treatment of choice. We emphasize that hemodiafiltration should begin as soon as MNMS is diagnosed.

Emergency Coronary Artery Bypass Grafting for Acute Coronary Syndrome / 日本心臓血管外科学会雑誌

Emergency coronary artery bypass grafting (CABG) for the treatment of acute coronary syndrome is still associated with increased operative risk and postoperative morbidity. Thirty-five patients underwent CABG for the treatment of medically refractory unstable angina (UAP), 42 patients for acute myocardial infarction (AMI) and 7 patients for post-infarction angina (PIA). The UAP patients received 2.8 distal anastomoses on average. Five patients (14%) died postoperatively, 3 of them due to perioperative myocardial infarction (PMI). In the AMI patient group, 29 patients were in shock and 3 patients were in cardiac pulmonary arrest (CPA) preoperatively. They received an average of 2.8 distal anastomoses. Fourteen patients (33%) died postoperatively. Ten of them died of postoperative myocardial failure. The operative mortality was extremely high in the shock state patient group (41%) and CPA state patients group (100%). Poor operative results were anticipated in those patients whose infarct-related artery was not recanalized preoperatively. All patients survived the CABG in the PIA group. It was concluded that reduction in mortality in the group of patients undergoing emergency CABG required highly refined myocardial preservation techniques to prevent PMI and to limit intraoperative myocardial damage, as well as powerful mechanical assist systems to provide support in cases of the postoperative myocardial failure.

Assessment of Left Ventricular Function by Doppler Echocardiography in Pediatric Cardiac Surgery / 日本心臓血管外科学会雑誌

Pre- and postoperative left ventricular (LV) function was assessed by Doppler echocardiography in 95 infants who underwent open heart surgery during the past two and half years. The patients were divided into three groups: 43 patients with ventricular septal defect (VSD group), 37 with atrial septal defect (ASD group) and 15 with the tetralogy of Fallot (TOF group). Echocardiography was performed before and at an early stage after surgery (average: 11.6 days) in all cases. The forward flow velocity pattern was evaluated by Doppler echocardiography, placing the sample volume at the pulmonary vein (PV) and the LV inflow portion. At the PV, the peak velocity of the S wave during systole (p-PV_S) and the D wave during diastole (p-PV_D) in patients with ASD were significantly lower (<i>p</i><0.01) postoperatively. In patients with VSD, only p-PV_D was significantly lower (<i>p</i><0.05) postoperatively, showing a decrease of pulmonary blood flow. These results are thought to reflect a difference in the compliance of the left atrium between the two groups. At the LV inflow portion, the ratio of peak velocity of the wave during atrial systole to R wave on rapid inflow during diastole (A/R) was significantly lower in patients with VSD (<i>p</i> <0.01) postoperatively. At the same time, LV ejection fraction and fractional shortening were significantly lower (<i>p</i><0.01), but these values remained within the normal range. These results suggest that LV can maintain a sufficient systolic performance against the decrease in preload and the increase in afterload as well as the improvement of diastolic function during the early period after surgery in the VSD group. In patients with ASD or TOF, there were no significant differences in parameters of LV function between preoperative and postoperative periods.

A case report of an extended aortic arch anastomosis for an infant with the persistent fifth aortic arch associated with atresia of the fourth aortic arch / 日本心臓血管外科学会雑誌

The persistent fifth aortic arch is rare vascular anomaly. To our knowledge, this is the 24th reported case of the persistent fifth aortic arch. This patient was a 31 days old male infant and had the persistent fifth aortic arch associated with atresia of the fourth aortic arch, patent ductus arteriosus, a double-outlet right ventricle, and a mesocardia. He underwent a fifth aortic arch division and an extended aortic arch anastomosis with a division of ductus arteriosus. There was no blood pressure gradient between upper and lower limbs after the repair. However, no weaning from a cardiopulmonary bypass after the subsequent radical operation for double-outlet right ventricle caused his death.