Coronary Artery Bypass Grafting Using Bilateral Internal Thoracic Arteries / 日本心臓血管外科学会雑誌

The internal thoracic artery (ITA) has been established as the preferred conduit for myocardial revascularization. Several reported improved late results of coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (BITAs). In our institute, BITAs have been used for CABG from 1993. Since 1995, the indications for use of BITAs were extended to high risk patients. Between January 1995 and December 1997, 119 patients received BITAs for coronary artery revascularization. Right ITAs were anastomosed to the left anterior descending arteries (65%), the diagonal branches (7%), the left circumflex arteries (12%) and the right coronary arteries (10%). In 8 patients (7%), free right ITAs were used to bypass between proximal and distal portions of the right coronary artery. The hospital mortality rate was 4.2%. Regarding hospital morbidity, there were 2 patients with sternal infection and 2 patients with LOS postoperatively. There was no reoperation for bleeding. No significant difference was observed in the rate of wound infection or rate of operation without blood transfusion between the patients having BITAs grafting and those having unilateral ITA or saphenous vein grafting only, during the same period. Diabetes mellitus, older age, feminine gender, reduced ejection fraction and urgent operation are known risk factors for CABG. Among patients with these factors, no significant difference was observed in hospital mortality rate between patients with BITAs grafting and those with unilateral ITA grafting. The operative results of CABG using BITAs were considered to be satisfactory.

Solitary Interruption of the Aortic Arch in an Elderly Patient / 日本心臓血管外科学会雑誌

A 67-year-old man was hospitalized due to congestive heart failure. The blood pressure was 180/72mmHg in the right arm and 100/70mmHg in the right leg. Aortography revealed that the aortic arch was completely interrupted just distal to the origin of the left subclavian artery and the descending aorta was clearly outlined by contrast medium coming from well-developed collateral vessels. There was no congenital anomaly such as PDA or VSD except for the interruption of the aortic arch. The final diagnosis was solitary interruption of the aortic arch (type A). An extra-anatomical bypass using a 16mm woven Dacron graft was placed from the ascending aorta to the descending aorta at the level of the diaphragm with cardiopulmonary bypass. The pressure gradient across the interruption disappeared immediately after opening the graft. Although he had perioperative myocardial infarction in the area of the right coronary artery, he recovered fully and when discharged he was in NYHA class 1 condition.

Arterial Switch Operation for Taussig-Bing Anomaly / 日本心臓血管外科学会雑誌

From 1985 through 1994, 12 consecutive patients with Taussig-Bing anomaly underwent an arterial switch. Age at operation varied from 8 to 42 months (mean 21 months). Coarctation of the aorta was present in 6 patients (including 4 with hypoplasia of the aortic arch), interruption of the aortic arch in one, straddling mitral valve in one and subaortic stenosis in two. The relationship of the great arteries was D-transposition in 11 patients (oblique in 6 and anteroposterior in 5) and side-by-side in one. Eleven patients had previous palliative surgery. Pulmonary artery banding was done in 11 patients, Blalock-Hanlon in 3, carotid flap aortoplasty in 3, subclavian flap aortoplasty in 2, extended aortic arch anastomosis in 2 and ligation of PDA in 1. The Lecompte maneuver was adopted in all but one patient with side-by-side great vessels. Intraventricular reconstruction was done through the right ventricle in 11 patients and through the right atrium in one who underwent one-stage repair. There was one early death, which was related to thrombosis of the superior mesenteric artery. One patient with side-by-side great vessels died at home 6 months after the arterial switch operation. The suspected cause of death was myocardial infarction due to compression of the left coronary artery by the pulmonary artery. In the follow-up of 10 patients ranging from 1.8 to 9.4 years (average 6.3 years), one required reoperation for pulmonary stenosis. We conclude that two-staged arterial switch operation of Taussig-Bing anomaly with D-transposition can be performed with low mortality, but there seems to be some risk of the compression of the left coronary artery in the original Jatene method for Taussig-Bing anomaly with side-by-side great vessels.

Two Cases of Successful Thrombolytic Therapy for Unilateral Thrombosed Leaflet of a St. Jude Medical Valve in the Mitral Position in a Child / 日本心臓血管外科学会雑誌

Case 1 was a 2-year-old girl who underwent mitral valve replacement with a St. Jude Medical valve for severe mitral regurgitation 14 days following common atrioventricular canal defect correction. The postoperative course was uneventful, but an unilateral thrombosed leaflet of a St. Jude Medical valve was observed 3 times by echocardiography and fluoroscopy. Thrombolytic therapy with urokinase was done each time and the thrombus was successfully dissolved. Case 2 was a 1-year-old girl who underwent closure of ventricular septal defect and mitral valve replacement with a St. Jude Medical valve for ventricular septal defect, severe mitral regurgitation and pulmonary hypertension. Unilateral thrombosed leaflet of the St. Jude Medical valve and poor left ventricular function were found by echocardiography 11 days after the operation. Thrombolytic therapy with urokinase was successfully performed without any complications. Thrombolytic therapy with urokinase was considered to be effective treatment for unilateral thrombosed leaflet of a mechanical bileaflet valve prosthesis in a child. Poor left ventricular function might be one of the causative factors of unilateral thrombosed leaflet of a mechanical bileaflet valve prosthesis.