Aortic Valve Repair for Infective Endocarditis of an Aortic Valve / 日本心臓血管外科学会雑誌

Infective endocarditis of the aortic valve tends to cause structural damage such as aortic root abscess, and aortic valve replacement is the standard treatment. However, there have been several reports on aortic valve repair for the treatment of infective endocarditis, and it has subsequently emerged as a feasible alternative to aortic valve replacement in selected patients. We report a case of aortic valve repair for infective endocarditis of the aortic valve caused by α-hemolytic Streptococcus. A 50-year-old man was admitted to our hospital with a two-month history of fever of unidentified origin. Transthoracic echocardiography revealed infective endocarditis of the aortic valve. Transesophageal echocardiography confirmed vegetation in the right coronary and non-coronary cusps, and mild aortic regurgitation. Although infection was controlled by approximately one month of antibiotic treatment, there was markedly more severe aortic regurgitation compared to the previous examination. These findings were confirmed on transesophageal echocardiography, and residual vegetation on the right coronary cusp as well as a perforation in the non-coronary cusp were confirmed. Intraoperative findings revealed a perforation in the non-coronary cusp and dehiscence, with vegetation on the right coronary cusp. The vegetation was carefully removed, the non-coronary cusp perforation was repaired with a pericardium patch, and the defect on the right coronary cusp was directly sutured with 6-0 polypropylene. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation. The postoperative course was uneventful and the patient was discharged 7 days after surgery without any complications. Antibiotics were prescribed for 3 months, and transthoracic echocardiography was performed 5 days, 1 month, and 3 months after surgery. No evidence of recurrence of aortic regurgitation or infection of the aortic valve was observed.

Beating Heart Mitral Valve Replacement via Right Thoracotomy for Ischemic Mitral Valve Regurgitation after Coronary Artery Bypass Surgery / 日本心臓血管外科学会雑誌

Reoperative valve surgery is known to be more complex and associated with increased morbidity and mortality, especially for patients with patent coronary artery bypass grafts. A 69-year old man with a history of coronary artery bypass grafting was referred to our hospital with breathing difficulties and a heart murmur. Bypass grafts were all patent, but due to severe ischemic mitral valve regurgitation, we performed beating heart mitral valve replacement via right thoracotomy. The procedure was performed with video assistance, and both the anterior and the posterior chordae tendineae were preserved. The postoperative course was uneventful. He was discharged 7 days after surgery without any complications. This technique is a safe and feasible option for a mitral valve reoperation that avoids graft injuries, minimizes the risks of bleeding, and shortens the operative time.

A Successful Case of Prosthetic Valve Endocarditis with Previous Aortic Root Replacement / 日本心臓血管外科学会雑誌

<p>A 58 year-old man was referred to our hospital with a fever after dental treatment. He had undergone an operation for aortic root replacement 9 months earlier. <i>Streptococcus </i>species were cultured with venous blood culture. An echocardiogram revealed vegetation attached to the prosthetic valve. The prosthetic valve function was good and he did not suffer from heart failure, therefore he was treated with antibiotics. Five days after starting antibiotics, we observed embolization of the brain and the kidney as well as an elevation of his inflammatory reaction. Accordingly, we performed emergency surgery. There was no paravalvular abscess or valve dysfunction, so we simply resected the vegetation and debrided the surrounding tissue. Post-surgical antibiotic therapy was continued for 5 weeks and then he was switched to oral medication. Three years after surgery, he is free from any PVE recurrence.</p>

A Rare Complication after Tricuspid Annuloplasty / 日本心臓血管外科学会雑誌

We report a rare case of severe aortic regurgitation after mitral valve replacement (MVR) and tricuspid annuloplasty (TAP). An 83-year-old woman underwent MVR and TAP for mitral regurgitation and secondary tricuspid regurgitation. The early postoperative course was not eventful until 6 days after surgery. However, 7 days after surgery, she suffered from acute heart failure and transthoracic echocardiography showed severe aortic regurgitation. We performed a second operation 13 days after the first surgery. Intraoperatively, we found the annulus suture of the TAP just under the NCC-RCC commissure of the aortic valve. We speculated that the suture pulled the aortic valve annulus, resulting in severe aortic regurgitation. We removed the suture and replaced the aortic valve with bioprosthetic artificial valve. Postoperative recovery was uneventful, and she was discharged 22 days after the second surgical procedure.

Preoperative Blood Donation in Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

Preoperative blood donation is well known as one approach to reducing complications caused by homologous blood transfusion. The purpose of this study is to evaluate whether preoperative blood donation prior to coronary artery bypass grafting (CABG) reduces homologous blood transfusion. The subjects were selected from 151 consecutive patients who underwent CABG between October 1996 and October 1998. Of the 151 patients, 76 made preoperative blood donations (group A). Results in this group were compared with those obtained in the control group consisting of the subjects who received CABG without preoperative blood donation (group B, <i>n</i>=75). Both groups were matched for age, sex, preoperative hematocrit, cardiopulmonary bypass time, blood transfusion index (BTI; body weight×preoperative hematocrit). There were no significant differences between the two groups in terms of age and mean bypass duration. Homologous blood requirements were significantly lower in group A (78.9%) compared to group B (61.0%). BTI in group A (2, 224±447) however, was higher than that in group B (2, 129±515). In our study, preoperative blood donation was very effective to reduce homologous blood transfusion in coronary artery bypass grafting.

A Successful Anatomical Reconstruction for Mycotic Abdominal Aortic Aneurysm with Infectious Abcess / 日本心臓血管外科学会雑誌

Mycotic aortic aneurysm is a rare disease which is caused by bacterial infection of the aortic wall, grows rapidly with subsequent rupture and has high mortality. We report a case of successful anatomical reconstruction for mycotic abdominal aortic aneurysm with infectious abcess. A 59-year-old man who was found to have an impending rupture of abdominal aortic aneurysm underwent emergency anatomical reconstruction. At operation, an active infectious abcess was noted around the abdominal aorta. Successful management of this disease depends on early accurate preoperative diagnosis, complete resection and debridment of infected tissues, anatomical graft replacement and adjuvant antibiotic chemotherapy.

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.

An Operative Case of Primary Cardiac Angiosarcoma of the Left Atrium / 日本心臓血管外科学会雑誌

Primary cardiac tumors are comparatively rare. Primary cardiac angiosarcoma is the most common cardiac malignant tumor and the most common site of this tumor is in the right atrium. It is usually difficult to diagnose and treat this condition before death. The present case of primary cardiac angiosarcoma was located in the left atrium, which is very rare. A cardiac malignant tumor was suspected in this 56-year-old man based on chest MRI examination. The operation was performed successfully but its outcome was very poor.

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.

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.

Combined Operation of Abdominal Aortic Aneurysm and Colon Carcinoma-Perioperative Management of Combined Severe Coronary Three Vessel Disease. A Case Report / 日本心臓血管外科学会雑誌

We report a case who received a combined operation for abdominal aortic aneurysm (AAA) and colon carcinoma. The AAA was 7cm in diameter and the colon carcinoma was advanced without distant metastasis. To prevent contamination in the operative field, a temporary stoma was chosen instead of anastomosis for the partial colon resection. Since the patient suffered severe coronary three-vessel disease, we applied the same management as for cardiac surgery during the operation and postoperatively. There were no complications such as myocardial infarction. We assume that the number of patients with AAA complicated with malignant tumor or ischemic heart disease may increase in future. It is necessary to be careful and perform further investigations concerning operation method and perioperative management.

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.

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.