ABSTRACT
A 47-year-old man was admitted to our hospital complaining of chest and back pain. Enhanced CT scan revealed Stanford type A acute aortic dissection. The celiac artery (CA) was not enhanced and the superior mesenteric artery (SMA) appeared on the delayed phase. There was a small amount of pericardial effusion. Blood gas analysis showed metabolic acidosis. To treat mesenteric malperfusion, we initially performed thoracic endovascular aortic repair (TEVAR) by the PETTICOAT technique and stenting to CA and SMA. The acidosis gradually normalized after TEVAR. We then performed surgical central repair (total arch replacement). He temporarily showed paraplegia after the operation but soon recovered by treatment for spinal ischemia. He was discharged 68 days post operatively without any complication. Surgical central repair is not always effective for treating organ ischemia, so endovascular repair before surgical operation is sometimes taken into consideration.
ABSTRACT
Distal anastomosis during total arch replacement (TAR) for thoracic aortic aneurysm (TAA) is often difficult to perform because of the limited surgical view. The most common methods available are direct anastomosis of a 4-branched graft to the distal aorta, or stepwise anastomosis with the elephant trunk procedure. However, the stepwise technique requires graft-to-graft anastomosis, which is often associated with bleeding. In the present study, we developed a new approach, which we have termed the “Branched Graft Inversion technique”, which does not require anastomosis between grafts, and facilitates anastomosis with a view equal to that in the stepwise technique. A 65-year-old man with a diagnosis of saccular-type thoracic aortic aneurysm was admitted. Cardiopulmonary bypass was established by cannulating the ascending aorta and femoral artery via a median sternotomy. We performed distal anastomosis under selective cerebral perfusion during hypothermic circulatory arrest (25°C). An inverted branched graft was inserted into the descending aorta and anastomosed using mattress and running sutures together with outer reinforcement with a Teflon felt strip. The distal end of the inverted branched graft was then extracted, and reconstruction of the neck vessels and proximal anastomosis were performed. Our newly developed Branched Graft Inversion technique was useful during TAR for TAA.
ABSTRACT
A 51-year-old man admitted to our hospital because of an ECG abnormality pointed out by his local doctor. He had been hospitalized for scarlet fever at age 10. A coronary artery CT scan showed coronary artery aneurysm of the left main trunk (LMT), and coronary angiography showed 3-vessel disease including a chronic total occlusion of the right coronary artery (RCA). We performed conventional coronary artery bypass grafting (CABG) using an arterial graft and aneurysmectomy. The patency of the graft was confirmed by coronary angiography postoperatively. The pathological diagnosis of the coronary aneurysm was Kawasaki disease. CABG is a standard procedure for coronary artery aneurysms with Kawasaki disease. However, there are no established treatment guidelines on whether to perform aneurysmectomy. We chose CABG with aneurysmectomy because of the possibility of intra-aneurysmal thrombosis leading to peripheral occlusion, and the cause of the coronary artery aneurysm could not be determined. However, even if additional treatment by percutaneous coronary intervention (PCI) is not possible, it is important to avoid occlusion of the graft.
ABSTRACT
A 62-year-old man had been given a diagnosis of atrial septal defect (ASD) 20 years previously, but the condition was left untreated. A heart murmur was detected on a routine health examination, so he visited our institution where a diagnosis of type II ASD and moderate tricuspid regurgitation was given. Cardiac catheterization revealed a pulmonary to systemic flow ratio (Qp/Qs) of 2.9, pulmonary vascular resistance of 3.1 units, and systolic pulmonary artery pressure of 90 mmHg. The patient underwent open surgery consisting of a patch closure of the ASD, and tricuspid annuloplasty. His pulmonary arterial pressure rose and his blood pressure dropped, and left cardiac failure developed on postoperative day (POD) 2. The administration of catecholamines and a phosphodiesterase (PDE) III inhibitor failed to correct the left cardiac failure. We performed intra-aortic balloon pumping (IABP) immediately, and his hemodynamic condition stabilized. The IABP catheter was removed on POD 10. The postoperative development of circulatory failure suggested that it was almost too late for surgery for ASD. It has been believed that surgery for ASD is relatively safe. However, it seems that, the considering the possible occurrence of postoperative cardiac failure in elderly patients with accompanying pulmonary hypertension, careful postoperative management is necessary.
ABSTRACT
In Japan, few surveys have evaluated the structure and clinical process of cardiovascular surgery programs. We mailed a questionnaire to all 149 facilities participating in the Japan Adult Cardiovascular Database as of April 1st 2007. We received responses from 129 facilities (response rate 86.6%). For CABG surgery, many facilities regard “IMA use (95.3%) ” and “off-pump surgery” is the first choice as a facility and recommend “discharge antiplatelets (89.9%) ” and “discharge antilipid (47.3%) ”. On the other hand most facilities did not made any recommendation regarding “preoperative beta blockers (72.9%) ” and “discharge beta blockers (60.5%) ”. The usage rates of preoperative beta blockers and discharge beta blockers were very low in Japan though their usage rates were relatively high in the United States.
ABSTRACT
Cardiac papillary fibroelastoma (CPF) is a rare benign cardiac tumor. It commonly arises from the left side heart valve. We present two rare cases of CPF that originating from the right side of the heart confirmed by surgical resection. Case 1 : A 67-year-old man was admitted for surgical resection of a cardiac tumor located in the right atrium. Transesophageal echocardiography revealed a mobile mass attached on the anterior leaflet of the tricuspid valve. The tumor was resected by open heart surgery. Histopathologic examination confirmed the tumor to be a CPF. Case 2 : A 68-year-old man was admitted for surgical resection of a tumor occurred from the tricuspid valve. Transthoracic echocardiography revealed a tumor attached to the medial leaflet. The tumor was resected. Histopathologic examination confirmed it to be a calcified mass. However, the surface of tumor had many papillary projections macroscopically. We redo the histopathologic examination, and confirmed the tumor as a CPF finally. In both cases, postoperative courses were uneventful.
ABSTRACT
A 67-year-old man had angina pectoris due to left main trunk stenosis of coronary artery was transferred to our hospital. Anticoagulation was achieved with a continuous intravenous infusion of 625IU/h heparin. Sixteen days after admission, his platelet count decreased to 14×10<sup>4</sup>/<i>μ</i>l, and further decreased to 9.1×10<sup>4</sup>/<i>μ</i>l 4 days later. Since we suspected HIT, heparin administration was immediately discontinued, and was substituted with argatroban. A definitive diagnosis of type II HIT was made by a serologic test confirming positive antibodies to the heparin-platelet factor 4 (PF4) complexes. After the platelet count recovered, we performed off-pump CABG (OPCAB) using argatroban. The postoperative course was uneventful and platelet counts was normal. The patient was discharged on the 13th postoperative day. Heparin-induced thrombocytopenia, which causes thrombosis, is a serious side effect of heparin therapy. It is not rare, and in such case argatroban can be useful as an anticoagulant during OPCAB.
ABSTRACT
We report a rare case of concomitant coronary artery disease, abdominal aortic aneurysm, and bile duct cancer. A 65-year-old man, who had been recognized to have jaundice in late November 2005, was found to have bile duct cancer, an abdominal aortic aneurysm with a diameter of 70mm, and coronary artery disease (with two severely diseased branches). To avoid extended operation, a two-stage operation was performed; at the first operation, off-pump coronary artery bypass surgery (LITA to LAD and Ao-SVG to 4 PD) and replacement of the abdominal aortic aneurysm by an artificial blood vessel with minimal incision were implemented. In 21 days after the cardiovascular surgery, the patient underwent pylorus-preserving pancreatoduodenectomy (modified Child method) in the second operation. After the two-stage operation, the patient showed a favorable outcome without any major complications. On the basis of the outcome of two-stage operation we successfully applied, we discuss the strategy for treatment of patients having both cardiovascular and abdominal malignant diseases, with reference to the literature.
ABSTRACT
A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: <i>n</i>=8, group F: <i>n</i>=1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F:87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2, 405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%), 2/13 (15%) respectively. Hospital mortality was 0/20 (0%), 2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.
ABSTRACT
We encountered a case of ascending aorta pseudoaneurysm due to a Freestyle-valve free-wall fistula after a modified Bentall procedure with the button technique. A 60-year-old man with Marfan's syndrome who contracted annuloaortic ectasia presented with the onset of Stanford A type acute aortic dissection 3 years ago. The patient underwent aortic root replacement with a Freestyle-valve and ascending and hemi-arch aortic replacement. Thirty-seven months after this operation the patient was re-operated because of pseudo-ascending aorta aneurysm. The cause of the pseudo-aneurysm was a fistula of the Freestyle-valve free-wall and the left coronary artety (LCA) ostial reconstruction component. The fistula was repaired by direct closure with pledgets. The patient was discharged from the hospital 24 days after the operation.
ABSTRACT
A 24-year-old woman with an abdominal aortic aneurysm (AAA) caused by mucoid medial degeneration of the aortic wall in the absence of Marfan syndrome is reported. She required a Y-shaped graft replacement of the abdominal aorta through a minimal incision and recovered successfully.
ABSTRACT
Upper ministernotomy is frequently selected in aortic valve replacement by minimary invasive cardiac surgery. However, retrograde cardioplegia cannulae cannot be inserted to some sites. CT examinations in our department revealed that lower ministernotomy can be used for surgery of the aortic valve in many Japanese cases. The usefulness of 2 approaches was examined in 68 cases with aortic valve disease who received aortic valve replacement by minimary invasive cardiac surgery from January 1997 to March 2002: Those who received upper ministernotomy (U group) and those who received lower ministernotomy (L group). Retrograde cardioplegia is frequently used in aortic valve replacement for myocardial protection. Those in the L group showed effectiveness in myocardial protection and in securing the operation field except in cases who were switched to full sternotomy. In the L group, the MAZE operation was performed and no significant differences were observed in aortic cross-clamping time, artificial cardiorespiratory time, operation time, bleeding amount and other factors. Lower ministernotomy was more effective than upper ministernotomy in myocardial protection by retrograde cardioplegia and securing the operation field in aortic valve replacement by minimally invasive cardiac surgery.
ABSTRACT
To reduce surgical invasion, we recently used a limited incision through a retroperitoneal approach in the abdominal aortic surgery. Between May 2001 and March 2002, 18 patients who had infrarenal aortic aneurysm, iliac aneurysm, or aortoiliac occlusive disease were surgically treated using a new approach at Dokkyo University Koshigaya Hospital. Although 1 patient with a short aortic neck had to be converted to conventional surgical incision, the remaining 17 patients were successfully treated with the limited incision (range, 6-10cm). Operative time and intraoperative blood loss were 275.2±62.9min and 968.5±473.8ml, respectively. None of these patients required homologous blood transfusion in the perioperative period. All patients were extubated in the operation room. Oral feeding and mobilization started on day 1.6±0.5 and 1.4±0.9, respectively. Furthermore, all patients were discharged home without serious complications such as postoperative ileus and perioperative death. These results show that the limited incision through a retroperitoneal approach is safe and effective in the abdominal aortic surgery. This technique maintains quality outcome while reducing surgical invasion.
ABSTRACT
Effects of amrinone and dibutyryl cyclic AMP (DBcAMP) on hemodynamics and myocardial metabolism were studied in 16 patients in the early postoperative period following open-heart surgery. Amrinone was administered continously at 10μg/kg/min for 5 hours and DBcAMP at 12μg/kg/min was infused concomitantly for the last 1 hour. Amrinone increased SVI, and decreased HR, PCWP, arterial systolic blood pressure, double product and central temperature difference significantly. Following concomitant administration of DBcAMP for 1 hour, further increase of CI, O<sub>2</sub> delivery, blood sugar and insulin were observed. Significant decrease of excess lactate from 9.31±3.27 to -1.31±1.83mg/dl (<i>p</i><0.05) showed that anaerobic metabolism improved in the myocardium after amrinone administration, and the effect improved further to -3.64±1.8mg/dl following concomitant administration of DBcAMP. These data demonstrate that amrinone has beneficial effects on hemodynamics and myocardial metabolism, and following supplementary administration of DBcAMP, further improvement in hemodynamics was observed.
ABSTRACT
A case of isolated left coronary artery ostial stenosis treated successfully by the saphenous vein patch plasty is reported. A 49-year-old woman was referred for surgery because of unstable angina with subendcardial infarction on ECG. Coronary angiogram showed isolated severe stenosis of left coronary artery ostium without stenotic lesion in the periphery and right coronary artery. At surgery, the aorta was incised obliquely downward to the left coronary ostium and this incision was further extended 8mm distally in the main trunk. Atheromatous left coronary ostium was enlarged with the saphenous vein patch. Postoperatively, angina disappeared and aortic root angioram revealed a well dilated ostium. At 1 year follow-up, the patient remains asymptomatic.
ABSTRACT
Preoperatively, hypertrophic non-obstructive cardiomyopathy with asymmetrical septal hypertrophy was found in a 66-year-old man with a chief complain of effort angina whose CAG showed stenosis of 70% in LCA (seg 5) and 100% in RCA (seg 1) with collaterals from LAD. Although graft flows, 240ml to LAD and 28ml/min to RCA, were obtained, it was necessary to place the patient on the assisted circulation and catecholamines when the weaning from CPB was being tried due to “stone heart” despite patient had been on IABP during surgery and short anoxic arrest time of 44min. Postoperative hemodynamic recovery was slow with low cardiac output improved lately by the continuous use of IABP and DBcAMP. Catecholamines and vasodilators often cause disturbance of hemodynamics in hypertrophic obstructive type but seem to be effective in non-obstructive type. Importance of myocardial protection, use of IABP, careful administration of β-stimulants and DBcAMP are discussed in surgery of patients with cardiomyopathy.