Clinical Experience with Terumo Large Diameter Graft (Triplex)-Results of a Multicenter Clinical Trial- / 日本心臓血管外科学会雑誌

We conducted a clinical study on a newly developed large diameter vascular graft (Triplex^®, Terumo Corporation, Tokyo, Japan) with a non-biodegradable material used as sealing material, to evaluate its effectiveness and safety. Triplex^® grafts were implanted in 170 patients with either aneurysmal or occlusive arterial disease in either the thoracic artery, abdominal artery or iliac arteries, between October 2001 and March 2003. The patients consisted of 141 men and 29 women with an average age of 69.0±10.0 years old (mean±SD). In 82 patients, Triplex^® was implanted for the thoracic artery area, in 88, for the abdominal artery area. The cumulative graft patency rate 12 months after implantation was 100.0% in each area, there was no any abnormality such as occlusion or rupture from the trunk of Triplex^®. The distension ratio, which is the index of the dilatation resistance, was 1.03±0.06 as a whole (<i>n</i>=139), 1.03±0.06 in the thoracic artery area (<i>n</i>=73), 1.03±0.06 in the abdominal artery area (<i>n</i>=66). In other words the dilatation of Triplex^® was hardly observed. As manipulability during the operation, the following characteristics were evaluated; anastomosis, resistance to fraying, hemorrhage, conformability with the host vessel. Triplex^® was evaluated as “good” in 75% of all items accounted for 75% or more. A transitory rise thought to be due to the surgical stress immediately after the operation because of the change of temperature and laboratory findings (CRP, WBC) between implantation and discharge was observed, but then recovered to the normal levels of each patients at discharge and the re-elevation was not recognized. In 90 patients, 277 adverse events occurred. Although in 33 adverse events in 21 patients a causal relation with Triplex^® could not be excluded, most of them were already known events as complications which could occur after operation on the aorta. Therefore, it was confirmed that Triplex^® has certain advantages: 1) good manipulability, 2) good patency and dilatation resistance, 3) no inflammatory reaction related to Triplex^®, as a graft for the aorta.

Surgical Treatment for a Trauma-Caused Cardiac Rupture / 日本心臓血管外科学会雑誌

The survival rate of patients with cardiac rupture due to a blunt trauma is low, therefore it is necessary to have a well-defined diagnostic and treatment plan in order to improve the survival rate. In 8 such patients transthoracic echocardiograms at the time of arrival at our hospital showed pericardial effusion with cardiac tamponade in all patients. The mean time between suffering the injury and arriving at the hospital was 186±185min, and the mean time between arrival and being brought to the operating room was 82±49min. Preoperative pericardial drainage was performed in 2 patients, and percutaneous cardiopulmonary support system was used in 2 patients. The rupture site was in the right atrium in 3 patients, the right atrium-inferior vena cava in 1 patient, the right ventricle in 2 patients, the left atrium in 1 patient, and the left ventricle in 1 patient. Extracorporeal circulation was used in 4 patients, and the injured site was repaired. We were thus able to save the lives of 6 of the 8 patients (survival rate 75%). Transthoracic echocardiography was easy to perform and effective for making an accurate diagnosis. Many such patients tend to have multiple traumas, but, if the patient is in a state of shock due to cardiac tamponade, the patient should be moved immediately to the operating room. It is important to provide circulatory maintenance until surgery, and pericardial drainage and PCPS are also effective additional treatment modalities.

A Successful Surgical Treated Case of Traumatic Rupture of the Distal Descending Thoracic Aorta above the Diaphragm / 日本心臓血管外科学会雑誌

A 24-year-old man was transferred to our hospital because of traumatic rupture of the thoracic aorta suffered in a traffic accident. On admission, he had recovered from shock and was alert. Chest CT showed massive hematoma around the total extent of the descending aora and the intimal flap at the diatal descending aorta. We performed an emergency operation. Through left thoracotomy, we found dilatation of the descending aorta. Epiaortic echo revealed that the aortic intima was completely transecred between Th 10 and Th 11. The pseudoaneurysm was replaced with a Hemashield vascular graft under partial cardiopulmonary bypass. The intercostal artery was preserved. His postoperative course was uneventful and paraplegia was not seen. We reported a rare case of traumatic rupture of the distal descending thoracic aorta above the diaphragm followed by successful surgical treatment.

A Case of Successful Aortic Fenestration for Renal Failure Associated with Aortic Dissection / 日本心臓血管外科学会雑誌

A 72-year-old woman suffered sudden back pain 42 days after ascending aortic replacement for retrograde acute type A aortic dissection. Computed tomography (CT) revealed type B aortic dissection and a stenotic true lumen at the abdominal aorta. The celiac artery and the superior mesenteric artery (SMA) branched from the true lumen, but bilateral renal arteries were not found by DSA. Infrarenal abdominal aortic fenestration was performed at 6th day from onset, because of progressive renal dysfunction. Intestinal ischemia was not confirmed by laparotomy. After the Infrarenal aorta was clamped and transected, the proximal intima was resected in a U-shape. The proximal stump which was reinforced with teflon felt was anastomosed to an 18mm woven graft. Distal anastomosis was carried to the true lumen was carried out with closure of the false lumen. Regaining flow into the collapsed true lumen was observed by epiaortic echography. Postoperatively, continuous hemofiltration was required for several days until renal dysfunction was improved. CT showed reasonable expansion of the true lumen, and no findings of visceral ischemia except for partial infarction of the left kidney. DSA revealed that bilateral renal arteries were perfused from the true lumen through the fenestration. Neither aortic dilatation nor new ischemia have been recognized, but further close observation is necessary.

A Case of Combined Acute Aortic Dissection and Abdominal Aortic Aneurysm with Hemolysis / 日本心臓血管外科学会雑誌

Concomitant occurrence of acute aortic dissection and atherosclerotic aneurysm is rare. In such a circumstance, rupture of the existing aneurysm is the more likely scenario. In general, atherosclerotic plaque frequently serves to terminate the dissection process. A 65-year-old man with an abdominal aortic aneurysm was admitted due to severe back pain. Emergency CT showed acute aortic dissection (Stanford B) with a partially thrombosed pseudo-lumen and fusiform abdominal aortic aneurysm. Hemolysis occurred due to compression of the true lumen by the thrombosed pseudo-lumen. Emergency abdominal aortic graft replacement was performed successfully.

Emergency Aortic Root Remodeling for Rupture of a Large Ascending Aortic Aneurysm / 日本心臓血管外科学会雑誌

Aortic valve preservation is indicated in cases of aortic regurgitation caused by sinotubular junction (STJ) dilatation with ascending aortic aneurysm. We performed aortic remodeling using a tailored Dacron graft for the rupture of a large ascending aortic aneurysm. The patient was a 68-year-old woman. She was admitted in shock with cardiac tamponade. Chest CT showed a large ascending aortic aneurysm, 11cm in maximum diameter. Echocardiography demonstrated moderate cardiac effusion and massive aortic regurgitation. The ascending aorta was dilated from the STJ to the innominate artery, but the aortic valve appeared normal. We decided to preserve the native aortic valve. We performed aortic root remodeling using a 26mm Dacron graft (Yacoub's procedure). An intraoperative endoscopic study revealed the disappearance of aortic regurgitation (AR). The coronary arteries were reconstructed by the Carrel patch technique. Postoperative aortography revealed trivial AR, and the patient was discharged two weeks after the operation. We conclude that this technique avoids the complications associated with mechanical valve implantation and necessary lifetime anticoagulation.

Two-Staged Operation for Multiple Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 69-year-old man was admitted for treatment of thoracic aneurysm. DSA revealed multiple aortic aneurysms: three true aneurysms which were located at the distal arch, the thoraco-abdominal aorta at the diaphragm level and the infrarenal abdominal aorta, 60mm, 55mm and 55mm in diameter, respectively and two pseudo-aneurysms which were located in the abdominal aorta just below the right renal artery and the right common iliac artery. We decided to perform a two-staged operation. Before the first operation, 1, 200ml of autologous blood was stored for perioperative blood transfusion. Initially, total arch replacement was performed using deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. One month after the first operation, total thoraco-abdominal aorta replacement was performed by a retroperitoneal approach with mild hypothermia. The Th 9, 10 and 11 intercostal arteries were reconstructed. Distal anastomosis was performed at both common iliac arteries. Blood transfusion was not required for blood pooling and reduction of priming volume in the cardiopulmonary bypass system.

Evaluation of Postoperative Cardiac Function in Severe Ischemic Heart Disease Associated with Decreased Ejection Fraction / 日本心臓血管外科学会雑誌

This clinical study was peformed to clarify the postoperative cardiac functions after coronary artery bypass graft surgery in the cases associated with decreased left ventricular ejection fraction (EF) or increased end-diastolic volume index (EDVI). The patients were divided into two groups by preoperative EF. The EF of Group I ranged from 31 to 39% in 42 cases, and the EF of Group II was below 30% in 27 cases. Several parameters of cardiac function such as EF, peak ejection rate (PER), peak filling rate (PFR) or early diastolic peak filling rate were evaluated with radionuclide ventriculography. Postoperative mean values of these parameters significantly improved in both Group I and Group II compared to preoperative values. Although these parameters and left ventricular wall motion did not improve in the 7 cases with an EDVI over 140ml/m² in Group II, the clinical results of these 7 cases were good during the follow-up period except one case which preoperatively had frequent ventricular arrythmia. The clinical condition improved remarkably in the 3 patients who had preoperative angina pectoris among these 7 cases. Surgical indications must be carefully determined in cases with increased EDVI and frequent ventricular arrythmia.

Acute Abdominal Aortic Occlusion: Two Cases of Successful Prophylaxis of Myonephropathic Metabolic Syndrome / 日本心臓血管外科学会雑誌

We report two cases, a 58-year-old male and a 60-year-old female with acute aortic occlusion probably ascribable to intracardiac thrombosis associated with atrial fibrillation. Thrombectomy was performed at about 5.5 hours and 4 hours respectively, after the onset of occlusion, and revascularization was successful. To prevent MNMS after revascularization, about 2, 000ml of blood was taken from the femoral vein of the male patient, and 1, 000ml of blood from the female patient, and this blood was returned in the form of abluted erythrocytes in transfusion through a cell saver to the patients. We suspected slight myoglobinuria after the operations, but they did not develop MNMS because a urine volume of about 3, 000ml was maintained by administration of infusion solution and diuretics and by replenishment of electrolytes and correction of acidosis. It was concluded that the technique involving the removal of a large volume of blood from distal veins and its transfusion through a cell saver was effective in preventing MNMS.

Evaluation of Left Ventricular Wall Motion after Mitral Valve Replacement with Preservation of Both Anterior and Posterior or Only Posterior Chordae Tendineae / 日本心臓血管外科学会雑誌

Left ventricular wall motion was evaluated after mitral valve replacement (MVR). MVR for mitral regurgitation (MR) was performed with preservation of both anterior and posterior chordae tendineae (Group I, <i>n</i>=12) or posterior chordae tendineae (Group II, <i>n</i>=9). MVR for mitral stenosis was performed with the preservation of the posterior chordae alone (MS Group, <i>n</i>=12). Postoperative regional wall motion was analyzed from the shortening fraction (SF) of the centerline method in 5 of antero-basal (AB), anterolateral (AL), apical (AP), diaphragmatic (DP) and posterobasal (PB) regions. The percentage of post-operative SF for preoperative value (%SF) was compared between Group I and Group II. The value of %SF improved much more in Group I than in Group II at the AL and AP regions. %EF was more significantly increased in Group I than in Group II, although postoperative ESVI and EDVI decreased in both groups. In the MS Group, EF, ESVI and EDVI did not change after surgery. The regional wall motion improved except in the calcified PB region. These results demonstrated that the preservation of both anterior and posterior chordae tendineae for MR was a useful procedure to improve postoperative LV regional wall motion. The preservation of posterior chordae for MS was sufficient to improve the regional wall motion except in the calcified submitral region.

Effect of Interval Training for 12 Weeks on Diastolic Filling of Left Ventricle During Mild Exercise / 体力科学

To clarify the mechanism responsible for the increase in stroke volume (SV) due to training, we investigated the effects of interval training on the left ventricle using M-mode echocardiography. Six healthy male subjects volunteered to undergo 48 training sessions for 12 weeks (4 sessions· week<SUP>-1</SUP>) One session consisted of five periods of exercise of 3-min duration on a cycle ergometer at a power output of 100% maximal O<SUB>2</SUB> uptake (Vo<SUB>2</SUB>max), interspersed with 2-min recovery cycling at 50%Vo<SUB>2</SUB>max. The echocardiograms at rest and during mild exercise (100W) were recorded before and after the training. The interval training significantly increased Vo<SUB>2</SUB>max. Although there was no significant difference in SV at rest before and after the training, the training increased SV significantly during exercise. Before the training, there was a significant difference in left ventricular enddiastolic dimension (LVEDD) and left ventricular end-diastolic volume (LVEDV) at rest and during exercise. However, after the training, LVEDD and LVEDV during exercise were significantly larger than those at rest. These results suggest that interval training for 12 weeks increases diastolic filling (elasticity) of the left ventricle during exercise in healthy young men, partly contributing to the increase in SV due to the training.

Injuries to Iliac Arteries Following Blunt Trauma of the Abdomen / 日本心臓血管外科学会雑誌

We present three cases of injured iliac arteries due to blunt abdominal trauma in traffic accidents. We performed emergency operations on these patients. Two of them received interposition of artificial prosthesis, and one received extraanatomical bypass. Fasciotomy was needed for compartment syndrome in 2 cases and one of them suffered a fractured pelvis with rupture of the ipsilateral femoral vein. One case was complicated with laceration of the mesentery. The postoperative course was almost uneventful in 2 cases but one died 8 days after operation because of subsequent multiple organ failure due to renal failure with necrosis of the small intestine of unknown cause. The diagnostic difficulties in such injuries depend on the existence of complications and different obstructive mechanisms from the penetrating injuries. Adequate and prompt diagnosis based on the clinically suspicious signs including weakness and discrepancy of the pulse are required.

Evaluation of Myocardial Protection and Postoperative Early Diastolic Function in Aortic Stenosis with Severe Concentric Hypertrophy / 日本心臓血管外科学会雑誌

Postoperative cardiac function and the occurrence of arrythmia depend upon myocardial protection during open heart surgery in severe concentric hypertrophy. The effect of myocardial protection was evaluated in terms of several released cardiac enzymes before and after reperfusion, and postoperative left ventricular (LV) cardiac function from cardiac pool scintigram in 21 cases with aortic stenosis (AS Group). These data were compared with 20 cases with aortic regurgitation (AR Group). Heart weight and aortic cross-clamping time were not significantly different in these two groups. The enzymatic values in peak total creatine-kinase (CK) and peak CK-MB fraction were higher in the AS group than in the AR group, and peak GOT was significantly elevated in the AS group (peak GOT: 93±32 in AS group, 64±17IU/<i>l</i> in the AR group, <i>p</i><0.01). Among the cases in the AS group, six cases with LV small cavity (LVDd<4cm) and severe concentric hypertrophy were associated with high values of released enzyme and the occurrence of ventricular arrythmia. Postoperative cardiac function was estimated from both systolic parameters such as LV ejection fraction (LVEF) or peak ejection rate (PER) and diastolic parameters such as peak filling rate (PFR) or early diastolic filling rate (1/3PFR). Postoperative LVEF and PER improved to normal control levels in the AS group with preoperatively depressed systolic function, although values were decreased in the AR group with impaired systolic function. The postoperative early diastolic peak filling rate did not recover to control levels in the AS group as well as the AR group, and was impaired in the AS group with severe concentric hypertrophy due to elevated chamber stiffness and the delay of time to peak filling rate. In severe concentric hypertrophy, we used several techniques for myocardial protection of terminal blood cardioplegia, and gradually increased reperfusion pressure and LV venting after reperfusion. Late results revealed a good clinical course in all 21 cases except for the occurrence of arrythmia in three.

Isolated Iliac Aneurysm with Arterio-Sigmoid Fistula. A Case Report / 日本心臓血管外科学会雑誌

We report a case of a solitary iliac aneurysm-fistula of the sigmoid colon. A 68-year-old male was diagnosed as having diverticulum of the sigmoid colon by barium enema at a near-by hospital with a major complaint of melena. He continued to have massive melena although he received sigmoid colectomy. His condition eventually deteriorated into shock and he was transferred to our department. Angiographic findings showed a left common iliac aneurysm. Under the diagnosis of a rupture of a sigmoid colon, emergency operation was performed including aneurysmectomy and bypass formation between the femoral and femoral artery as an extraanatomical bypass. The patient developed multipul organ failure following the sepsis and died 8 days postoperatively. An aneurysm-intestinal fistula is a complication of an aneurysm. The problem of this disease is the difficulty in making a definite diagnosis with high mortality rate. We should consider the possibility of an aneurysm-intestinal fistula for the patient with gastrointestinal bleeding of the unknown origin.

An Operative Case of Bilateral Coronary Arteries to Pulmonary Artery Fistula with Giant Saccular Aneurysm / 日本心臓血管外科学会雑誌

We reported an operative case of bilateral coronary arteries to pulmonary artery fistula with giant saccular aneurysm. This 68 year-old female was admitted for evaluation of chest oppression and heart murmur. On coronary angiography, the diagnosis was made as a coronary artery fistula originating from right coronary artery and left anterior descending artery, and draining into the main pulmonary artery. The operation was indicated by giant saccular aneurysm, high shunt ratio, and positive finding of ischemic change on exercise electrocardiogram. The closure of coronary fistula and aneurysmorrhaphy were performed under cardiopulmonary bypass. The aneurysm was 25×30mm diamater, and not found arteriosclerotic change in operative finding. The fistula was completely disappeared by postopertive coronary angiography. We concluded that curative operation for coronary artery fistula with giant aneurysm can be done with minimal risk under cardiopulmonary bypass.

A Case of Giant Popliteal Aneurysm with Compression Neuropathy in Behcet's Disease / 日本心臓血管外科学会雑誌

Behcet's disease is generally recognized as a chronic multi-system disease. Approxymately 8% of patients with Behct's disease will have serious vascular compilcations which is called vasculo-Behcet's disease. A male patient of 41 year old was admitted to our clinic, complaining pain of left popliteal fossa and hypesthesia of left lower leg. A popliteal aneurysm was found. Resection of the aneurysm and a saphenous vein graft were successfully performed. Neuropathy disappeared after the surgery. Aneurysms in Behcet's disease mainly appear in major arteries, and rarely in peripheral arteries. Compression neuropathy in the popliteal aneurysm of Behcet's disease has been rarely reported. Early resection of aneurysm before completion of neuropathy is recommended for succsessful outcome.

Rare complications for aortitis syndrome / 日本心臓血管外科学会雑誌

Rare complications-1) Sarcoidosis, 2) Amyloidosis, 3) Phycomycosis-following surgical therapy for aortitis syndrome are reported. Sarcoidosis occurred in 39 y.o. female following Bentall operation for AAE and AR was diagnosed by biopsy and was controlled with drug completely 1 year after the onset. Amyloidosis found in 56 y. o. male after AVR and AAo plication for AAE and AR started with severe diarrhea and the diagnosis was made by autopsy. Phycomycosis was diagnosed by necropsy in 49 y. o. female after CABG and thoraco-abdominal bypass operation. Poor control of inflammation and administration of gluco-corticoid are the common problems for the 3 cases. Aortitis syndrome is autoimmune disease and some immunological factor has a role for the cause of the three complications. We must be very strict about the administration of the gludo-corticoid and the control of the inflammation.