Surgical Treatment for a Coronary Artery Saccular Aneurysm Located in the Left Main Trunk / 日本心臓血管外科学会雑誌

A 67-year-old man was admitted to our hospital with a complaint of heart failure. He had a 12-year history of chronic renal failure and hemodialysis. Coronary angiography confirmed the presence of a saccular aneurysm originating from the calcificated left main trunk with coronary artery stenosis. The aneurysm was successfully treated by saphenous vein patch repair of the orifice and coronary revascularization of the left anterior descending and circumflex arteries. A histological examination of the aneurysm wall demonstrated coronary artery dissection. Postoperative coronary angiography 2 weeks after surgery revealed no evidence of residual aneurysm and showed patent bypass grafts.

The Case of a Patient with Femoral Artery Stenosis Caused by Angio-Seal^® Use Treated with Endoarterectomy / 日本心臓血管外科学会雑誌

In cases of hemostasis of the femoral artery where the sheath is removed after percutaneous catheterization, there is greater improvement in patient condition and shorter duration of hospital stay when arterial puncture closing devices are used rather than standard manual compression because the use of these devices results in shorter hemostasis and rest times. However, some complications due to these devices have also been reported. Here, we report a case of femoral artery stenosis due to Angio-Seal^® use in a 67-year-old woman. Embolization of the basilar artery aneurysm by endovascular treatment was performed at another institution ; the percutaneous puncture site was the right femoral artery. When this treatment was provided, hemostasis of the artery was performed with the Angio-Seal^®. About one month after the embolization, right intermittent claudication occurred after a 300-m walk. Echography and computed tomography (CT) angiogram showed 75% stenosis of the right common femoral artery, and therefore endoarterectomy of the artery was performed. The postoperative course was favorable and the ankle brachial index score improved from 0.82 to 1.15. In addition, CT angiogram showed resolution of the stenosis of the right common femoral artery and right intermittent claudication ameliorated. Based on the intraoperative views, it was suggested that the arteriosclerotic lesion had existed at the common femoral artery before the endovascular treatment and it might be the cause of the complication mentioned above. In order to prevent complications due to Angio-Seal^® use, it is important to examine the indications of the use of this device by evaluating the puncture site of the artery with echography and other diagnostic techniques before the insertion of a sheath.

A Case of Heparin-Induced Thrombocytopenia following Surgery for DeBakey Type I Acute Aortic Dissection / 日本心臓血管外科学会雑誌

A 73-year-old man underwent ascending aortic replacement and F-F crossover bypass for acute aortic dissection with right leg ischemia. He was treated postoperatively for acute renal failure due to myonephropathic metabolic syndrome (MNMS) with continuous hemodiafiltration. He suffered from acute graft occlusion and brain infarction on postoperative day (POD) 3. Although recovery of organ functions was observed, an unexpected decrease in platelet count occurred rapidly below 1.1×10⁴/μl on POD 6. We suspected heparin-induced thrombocytopenia (HIT) and all heparin administration was halted and argatroban was initiated at a dose of 0.2 μg/kg/min, with titration to achieve an activated partial thromboplastin time (APTT) of 1.5-3.0 times the initial value not to exceed 100 sec. The platelet factor 4-reactive HIT antibody was positive and definite diagnosed of HIT was made. Administration of warfarin started after the platelet count recovered to 10.0× 10⁴/μl on POD 36. Awareness of the clinical features and different presentations of HIT are essential for preventing severe complications associated with this disease.

Surgical Treatment of Active Infective Endocarditis: Determinants of Early Outcome / 日本心臓血管外科学会雑誌

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). <i>Streptococci</i> (27.5%) and <i>Staphylococci</i> (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (<i>p</i>=0.02), New York Heart Association class III or IV (<i>p</i>=0.02), a preoperatively unidentified pathogen (<i>p</i>=0.02) and concomitant operation for abscess and fistula (<i>p</i>=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (<i>p</i>=0.11). Multivariate analysis revealed that NYHA III-IV(<i>p</i>=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (<i>p</i>=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

A Case of Valve Repair in Mitral Valve Regurgitation Associated with Acromegaly and a Review of the Literature during the Last 2 Decades / 日本心臓血管外科学会雑誌

Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. A 62-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet, which was successfully repaired. At the age of 57 years, the patient was admitted due to heart failure without valvular disease. Acromegaly was diagnosed and a pituitary tumor was removed surgically. At the age of 62, a heart murmur was found, and moderate to severe MR was diagnosed. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. Histological examination showed myxomatous degeneration. The patient recovered uneventfully. During the last 2 decades, only 21 surgical cases of valvular disease associated with acromegaly were reported in the literature; mitral valve lesions in 10 patients (all with regurgitation), aortic valve lesions in 10 patients (7 with regurgitation and 3 with stenosis), and one with combined lesions of mitral and aortic valves. Since histology did not show specific changes in many reports, it is still unclear whether valve lesions are caused by a high GH hormone level. Although mitral valve replacement was recommended in the 1990s due to the fragility of valvular rings and their apparatus, mitral repair was performed in 5 recent cases and no recurrence has been reported.