Emergency Total Arch Replacement with J-Graft Open Stent Graft for Acute Type A Aortic Dissection, Requiring TEVAR for Stent Graft Stenosis / 日本心臓血管外科学会雑誌

<p>A 76-year-old man was admitted to our hospital to receive optimal medical therapy for acute type B aortic dissection with a thrombosed false lumen. Eighteen days after admission, computed tomography (CT) was performed because of back pain and showed new retrograde acute type A aortic dissection. Emergency total arch replacement was performed with the aid of a J-graft open stent graft (JOSG). Postoperatively, the blood pressure in the lower extremities decreased to 70% of systemic blood pressure without symptoms. Enhanced CT showed severe stenosis from the non-stent part of the aorta to the proximal part of the JOSG. On postoperative day 2, thoracic endovascular aortic repair (TEVAR) was performed for stent graft stenosis. The blood pressure of the lower extremities promptly recovered after the procedure, and the patient was extubated without any neurologic deficits on the next day. Postoperative CT demonstrated that the stent graft stenosis had been effectively alleviated. The patient's subsequent course was uneventful and he was discharged on postoperative day 24.</p><p>A JOSG should only be deployed after precise evaluation of the anatomy of the target aorta and careful attention should be paid to the length of the non-stent part of the graft in order to prevent unpredictable graft retraction that could cause stent graft stenosis. TEVAR is considered to be a good option to treat complications related to open stent grafts.</p>

Ruptured Acute Type A Aortic Dissection with Persistent Left Superior Vena Cava and Absence of a Bridging Innominate Vein / 日本心臓血管外科学会雑誌

Ruptured acute type A aortic dissection in a patient with persistent left superior vena cava (PLSVC) and absence of a bridging innominate vein is rare. A 71-year-old woman presented with a pain in the right side of the neck and nausea. Ruptured acute type A aortic dissection was diagnosed. CT scan revealed a persistent left superior vena cava and absence of a bridging innominate vein. Emergency hemi-arch replacement was performed. After CPB was established with right femoral artery return and right SVC (RSVC), IVC venous drainage was placed. An L-shaped venous cannula was directly placed into the LSVC. After core cooling, the ascending aorta was clamped and the right atrium was incised for retrograde cardioplegia. At a rectal temperature of 28°C, circulatory arrest was started and retrograde cerebral perfusion was performed through right and left SVC. Her postoperative course was uneventful. In cases of ruptured acute type A aortic dissection in a patient with persistent left superior vena cava (PLSVC) and absence of a bridging innominate vein, standard hemiarch replacement can be performed with direct venous cannulation of LSVC for reliable retrograde cardioplagia and retrograde cerebral perfusion.

Aortic Valve Replacement in Patients Aged 80 or Older / 日本心臓血管外科学会雑誌

With the progressive aging of the Japanese population, cardiac surgeons are increasingly faced with elderly patients. We have studied 29 consecutive patients, 80 years of age or older, who underwent aortic valve replacement at our institution between January 2000 and December 2003. Mortality, morbidity and late follow-up results were compared to those in 36 patients aged from 64 to 75 years old undergoing the same procedure over the same time period. The older patient group had a significantly higher incidence of calcified aortic stenosis and emergency operations and a higher score of NYHA functional class. Hospital mortality was 2 of 29 (6.9%) in the older patient group and 2 of 36 (5.6%) in the control group (ns). Postoperative renal failure and respiratory failure which needed prolonged ventilator support occured significantly more often in the older patient group. However, there was no significant difference between the 2 groups in terms of hospital stay. Almost all octogenarians showed improved NYHA functional class to class I or II after the operations. The actuarial survival rate was 89% in the older patient group and 78% in the control group at 3 years. The late survival rate and cardiac event-free rate were not significantly different between these 2 groups. Following aortic valve replacement, octogenarians, despite more compromised pre-operative status had good relief of symptoms, a favorable quality of life and a similar late survival to the younger patient groups. These findings support the recommendation that valve replacement should be performed in octogenarians with symptomatic aortic valvular disease.

A Case of Successful Transaortic Endovascular Stent Grafting for Distal Aortic Arch Aneurysm with Severely Calcified Chronic Aortic Dissection / 日本心臓血管外科学会雑誌

A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.

Malignant Hyperthermia after Surgical Repair of Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO₂, low level of PaO₂ and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/<i>l</i> and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.

A Case of Huge Aortic Arch Aneurysm with Unrevealed Aortopulmonary Fistula Resulting Intraoperative Pulmonary Artery Rupture after Total Arch Replacement / 日本心臓血管外科学会雑誌

A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.

Nonocclusive Mesenteric Ischemia after Off-Pump CABG / 日本心臓血管外科学会雑誌

An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.

A Case of Myocardial Abscess Complicating Mitral Valve Infective Endocarditis due to Klebsiella pneumoniae / 日本心臓血管外科学会雑誌

A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. <i>Klebsiella pneumoniae</i> was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.

Successful In Situ Repair for Mycotic Aneurysm of the Iliac Artery with Autologous Superficial Femoral Vein / 日本心臓血管外科学会雑誌

A successfully treated case of a 73-year-old man with mycotic aneurysm of the iliac artery combined with psoas abscess was reported. The operation consisted of débridement of the infected arterial wall with arterial reconstruction using autologous reversed superficial femoral vein and wrapping the graft and filling the defects with omentum. <i>Streptococcus pneumoniae</i> was grown from the psoas abscess culture. He had peritonitis by gangrenous cholecystitis postoperatively and underwent reexploration for correction of the peritonitis. After his second operation, the postoperative course was uneventful. He is doing well 18 months postoperatively. Venous morbidity after superficial femoral vein harvest is minimal. <i>In situ</i> reconstruction with autogenous deep leg veins is a successful option in patients with mycotic aneurysms.

Strategy for Stanford Type A Acute Aortic Dissection with Thrombosed False Lumen of the Ascending Aorta / 日本心臓血管外科学会雑誌

From 1995 till 1998, 21 cases of Stanford type A dissecting aortic aneurysm with a closed false lumen of the ascending aorta were treated in our institute. The patients were medically treated if the diameter of their ascending aorta stayed less than 50mm without recurrent dissection. Patients were categorized into three groups: Groups I, II and IIIR (retrograde dissection), according to the location of the entry analyzed by means of CT, angiography and operative findings. Seven cases of intramural hematoma (IMH) were included in this study. One case in Group II died of rupture and one case in Group IIIR died of multiple embolism caused by atrial fibrillation in the acute phase. One case in Group II died of stroke and one case in Group I died after surgery in the chronic phase. Four cases in Group I and II underwent surgery in the acute phase and five cases in Group I and II underwent surgery in the chronic phase, but only one case of Group IIIR required surgery. Six cases of IMH required surgery. The rates of freedom from operation at four years was 25%, 21% and 83% respectively (<i>p</i>=0.07). Essentially, Stanford type A dissection should be treated surgically even though the false lumen is thrombosed. However, in the case of retrograde dissection accompanied by an entry in the descending aorta, medical treatment may be a strategy option.

Aneurysms Arising from a Knitted Dacron Velour Graft Which Caused Acute Arterial Embolization / 日本心臓血管外科学会雑誌

A 67-year-old man suffered acute arterial occlusion caused by emboli from aneurysms in a right axillo-bifemoral graft using Cooley double velour knitted Dacron, which was inplanted 10 years and 10 months before the admission. The patient underwent urgent redo surgery; left axillobifemoral bypass with 6mm ringed PTFE graft and right femoropopliteal bypass with <i>in situ</i> saphenous vein were performed successfully. Several clinical experiences by others demonstrated that Cooley double velour knitted Dacron graft, manufactured before June, 1981, might have possible aneurysmogenic factors, therefore cases in which it has been employed should be followed up carefully.