Total Arch Replacement with a 150-mm J-Graft Open Stent Graft for a Syphilitic Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 66-year-old man was under observation as an outpatient for moderate aortic regurgitation and distal aortic arch aneurysm since 2005. He underwent surgery for gradual expansion of the distal aortic arch aneurysm. Preoperative enhanced computed tomography (CT) revealed a fusiform-type aortic aneurysm with a maximum short diameter of 63 mm. The aneurysm extended from the left subclavian artery to the descending aorta, 67 mm ahead. Based on the preoperative CT, a 150-mm open stent graft (OSG) was selected because of an adequate landing zone when inserted from the proximal site of the left subclavian artery. A 33-mm diameter graft was selected with a diameter 10% larger than that of the aorta at the landing zone. Moreover, the preoperative rapid plasma reagin (RPR) test was positive at 5.5 RU, and the fixed Treponema pallidum latex agglutination (TPLA) test was positive at 4,670 TU. He had undergone treatment for syphilis, and we concluded that the patient harbored antibodies after syphilis treatment. In the operating room, median sternotomy was performed. Cardiopulmonary bypass (CPB) was instated with bilateral axillary artery return, and superior vena cave (SVC) -inferior vena cave (IVC) venous drainage was placed. The aortic wall was strongly adherent to the surrounding tissue, similar to that observed in the aortitis syndrome. We performed aortic valve replacement during the systemic cooling. Under hypothermic circulatory arrest at 25°C with selective cerebral perfusion, the aorta was cut between the left common carotid artery and left subclavian artery. From this site, OSG was inserted to the level of the aortic valve. Total arch replacement was performed with a 30-mm bypass graft. Pathological findings indicated infiltration of lymphocytes and plasma cells around the feeding artery in the aortic aneurysm wall, and the aortic media wall showed fibrillation. Based on the intraoperative and postoperative pathologic findings, we diagnosed the patient with syphilitic aortic aneurysm, and started oral administration of amoxicillin 1,500 mg per day for 3 months. He was discharged on the 13th postoperative day without paraplegia, vocal cord paralysis, or other complications. Although syphilitic aortic aneurysm is rarely seen, it must always be considered as one of the causes of aortic aneurysm.

A Case of Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa after Aortic Valve Replacement / 日本心臓血管外科学会雑誌

The mitral-aortic intervalvular fibrosa (MAIF) is a fibrous skeleton between the mitral and aortic valves. We describe a case of a pseudoaneurysm of MAIF (MAIFPsA) 3 months after an aortic valve replacement. A 75-year-old man had undergone aortic valve replacement using a bioprosthesis (SJM Trifecta 23 mm). He developed congestive heart failure 3 months after surgery. Trans-esophageal echocardiography and multi-detector computed tomography detected a MAIFPsA and severe paravalvular leakage. The patient underwent a new operation. After the aortic prosthesis was removed, an orifice of the pseudoaneurysm, which was composed of the anterior mitral leaflet and the aortic annulus, were revealed. The defect was repaired with a bovine pericardial patch, sutured to the anterior mitral leaflet and aortic annulus. A new bioprosthesis (Carpentier-Edwards PERIMOUNT 21 mm) was implanted in the supra-annular position. His postoperative course was uneventful.

Correction of Severe Ebstein's Anomaly in a Neonate with Pulmonary Atresia / 日本心臓血管外科学会雑誌

We report the successful surgical treatment of severe Ebstein's anomaly in a female neonate with pulmonary atresia. Soon after birth, a heart murmur was audible and the baby became cyanotic. Echocardiography showed Ebstein's anomaly with pulmonary atresia. We started a LipoPGE 1 infusion for the open ductus arteriosus, but her uncontrollable heart failure necessitated surgery. Thus, when she was 8 days old, she was placed on cardiopulmonary bypass and we performed a triuspid valve orifice closure with right atrium plication and enlargement of the interatrial communication. She received a modified Blalock-Taussig shunt at the age of 60 days, but a prolonged mirulinone infusion was needed for her persistent heart failure. When she was 10 months old, we inserted a bidirectional Glenn shunt and she was discharged. Finally, when she was 30 months old, she had a total cavopulmonary connection. The patient is now asymptomatic, 18 months after her last operation.

Successful Surgical Treatment of Ruptured Abdominal Aortic Aneurysm Following Stanford Type B Acute Aortic Dissection / 日本心臓血管外科学会雑誌

A 72-year-old man presented with back pain and 3 days after admission, chest and abdominal CT scanning revealed the existence of infrarenal abdominal aortic aneurysm with Stanford type B acute aortic dissection and hemorrhage in the retroperitoneal space. The maximum diameter of the abdominal aortic aneurysm was 60mm. After treating with anti-hypertensive therapy under restrictive observation because of the patient's stable general condition, surgery was performed 45 days after admission. The dissection extended into the abdominal aortic aneurysm and all visceral arteries branched from the true lumen. The presence of thrombus in the preperitoneal space suggested a ruptured abdominal aortic aneurysm. Abdominal aortic aneurysm was replaced with a Y shaped graft and proximal anastomoses was performed with fenestration to prevent rupture of the proximal dissecting aorta. We report a rare case of ruptured abdominal aortic aneurysm following Stanford type B acute aortic dissection, which was operated on in the chronic stage. The patient is doing well.