A Surgical Case of Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery in Early Infancy / 日本心臓血管外科学会雑誌

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital defect, and few cases have been reported in the pediatric age group. Unlike the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), patients with ARCAPA are usually asymptomatic and often diagnosed incidentally. Here, we present a surgical case of a 2-month-old male who was suspected of having ARCAPA in the neonatal period. The patient was suspected of having ARCAPA due to the detection of a heart murmur and the results from an echocardiogram taken the 4th day after birth. Coronary angiography on the 37th day after birth showed the contrast flow to the pulmonary artery through the right coronary artery from the left coronary artery; thus, we diagnosed ARCAPA. Surgical intervention should be performed before the appearance of myocardial ischemia due to decreasing pulmonary artery pressure, so we performed reimplantation of the right coronary artery to the ascending aorta and patch plasty of the pulmonary artery at 2 months after birth. The patient was discharged from the hospital on the 16th day after the operation, and a 6-month postoperative coronary angiography revealed good right coronary flow and the disappearance of collaterals.

Staged Repair of Unilateral Absence of the Right Proximal Pulmonary Artery Using Autologous Azygos Vein Graft Interposition / 日本心臓血管外科学会雑誌

The isolated unilateral absence of a proximal pulmonary artery is a rare congenital lesion that presents various symptoms. Although some reports have shown one-stage reconstruction of the pulmonary circulation in infants, the two-stage approach is required in the situation of pulmonary arterial hypoplasia. In these cases, the usual approach is systemic pulmonary shunting for the first operation, to obtain growth of the pulmonary vascular bed, and then connecting bilateral pulmonary arteries for the second operation. Moreover, in the majority of patients without a right proximal pulmonary artery, some material is required for reconstructive surgery that corresponds to the patient's growth. A girl aged 2 years and 10 months with absent right proximal pulmonary artery, underwent modified Blalock-Taussig shunting with a free autograft of the azygos vein. The shunt was banded to prevent excessive pulmonary blood flow. Reconstructive surgery was performed 10 months after the first operation. At the second operation, growth of the right distal pulmonary artery and azygos autograft was satisfactory. Therefore, we used this autograft as an interposed graft of the right and main pulmonary arteries. Her postoperative course was uneventful. We advocate the usefulness of the azygos vein for graft material possessing the possibility of growth. This autograft is useful for pulmonary arterial reconstruction, such as the present case, and also may be useful for a systemic-pulmonary shunt, while growth is anticipated for more complex heart diseases.

An Alternative Method for Enlargement of Left Atrioventricular Valvular Annulus at Repeat Prosthetic Valve Replacement in Atrioventricular Septal Defect / 日本心臓血管外科学会雑誌

A 10-year-old girl was given a diagnosis of mitral stenosis due to a small prosthetic valve. She had undergone intra-cardiac repair operations for a complete atrioventricular septal defect by a two-patch method at 6 months after birth, and for left atrioventricular valve insufficiency by replacement with a mechanical prosthesis (SJM-HP-17mm) at 2 years of age. The cause of mitral stenosis was considered to be that the existing prosthesis was too small for her body growth. Reoperation was done with a trans-septal approach, but despite the resection of the old prosthesis and peripheral fibrous tissue her left atrioventricular annulus was not big enough to insert a larger prosthesis. We thus cut the previous VSD patch about 1cm toward the apex, and sutured a patch for annular enlargement. After this annular enlargement, we could insert a larger prosthesis (SJM-HP-21mm). Her postoperative course was uneventful. There was no left ventricular outflow obstruction and no worsening of her mild right atrioventricular regurgitation. There are few established procedures for enlargement of a left atrioventricular annulus. Our method presented here is safe and effective for left atrioventricular annular enlargement, but can only be applied to patients with atrioventricular septal defect.

Two Cases of Successful Treatment of Tracheo-Innominate Artery Fistula / 日本心臓血管外科学会雑誌

Tracheo-innominate artery fistula (TIF) is a relatively rare, highly lethal complication after tracheostomy. We report two cases of successfully managed TIF with relatively long-term survival after a massive hemorrhage from the tracheostomy site. Different approaches were employed for the temporary control of bleeding and in the subsequent surgery in these two cases, thus we examined the pros and cons of each approach. In Case 1, the bleeding was temporarily controlled using a long tracheostomy tube and orotracheal tube and by applying digital compression to the tracheostomy site. The right common iliac-to-right axillary artery bypass was then performed, followed by a median sternotomy to resect the injured innominate artery and to directly close the tracheal fistula. In Case 2, an over-inflated cuff was used after inserting the long tracheostomy tube to its full extent from the tracheostomy site, which was able to stop the bleeding for a while. This resulted in massive rebleeding when the cuff was remored while the patient was being transferred to the operation room. The patient underwent median sternotomy followed by anatomic innominate artery reconstruction using an ePTFE graft, and closure of the tracheal fistula was performed using autologous pericardium patch. In the treatment of TIF, prevention must be the greatest priority. If premonitory bleeding occurs (in the form of minor fresh bleeding), the patient must be evaluated immediately using bronchoscopy and CT imaging, and surgical intervention should be considered depending on the condition. If the bleeding is severe, the airway should be maintained and the bleeding should be temporarily controlled. We were able to control the bleeding in Case 1; however, in Case 2, we were unable to so since the tracheostomy tube was not long enough. After the surgery, we thought that the outcome might have been different if we had used the orotracheal tube instead of the tracheostomy tube and we believe this is one point that should be carefully considered. As for the procedures chosen for the TIF surgeries, anatomic revascularization of the innominate artery and closing the tracheal fistula are the procedures of choice when the operation field is not contaminated. However, when the field is contaminated (for example, in the case of a large fistula), extra-anatomic revascularization may be the only choice. This indicates that early evaluation and intervention of TIF are also important in terms of preventing infections and long-term prognosis.

Surgical Therapy for Prosthetic Graft Infection / 日本心臓血管外科学会雑誌

Five patients with vascular graft infections were surgically treated over a 16-year period. Primary diseases were arteriosclerosis obliterans in 3 cases and invasion of malignant diseases in 2 cases. The most common site of infection was the groin (3 of 5). <i>Staphylococcus aureus</i> was the most common pathogen. Administration of antibiotics, drainage and lavage with povidone iodine solution were performed in 4 patients (40-64 days). All patients underwent graft resection and reconstruction. Infected parts of the previous grafts were removed. Total removal of the previous graft was performed in 2 cases and partial removal was performed in 3 cases. To avoid re-infection, long extra-anatomical bypass was performed in 4 cases. The post operative courses of the five patients were uneventful.