A Case of Saved Transplanted Kidney by Axillo-Common Iliac Perfusion for Replacement of Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 58-year-old man underwent renal transplantation 26 years previously and had been treated with immunosuppressive drugs. He presented at the local hospital with backache symptoms during the waiting period prior to repair of an abdominal aortic aneurysm. Computed tomography revealed a retroperitoneal hematoma around the abdominal aortic aneurysm. He was admitted to our hospital and emergency straight graft replacement was performed. After clamping of the aorta, we performed axillo-common iliac perfusion to protect the transplanted kidney. The patient recovered without transplanted kidney dysfunction.

A Case of Aortic and Mitral Stenoses Recovered from Thrombocytopenia after Double Valve Replacement / 日本心臓血管外科学会雑誌

A 77-year-old-woman was hospitalized at our institution following the diagnosis of severe aortic and mitral stenoses. Although she had thrombocytopenia before surgery, bone marrow examination revealed no abnormality. Thrombocytopenia was thought to be caused by shear stress accompanying valvular diseases. She underwent surgery for the replacement of aortic and mitral valves and the resection of left ventricular outflow tract myocardium. Because the mitral valve involved the calcification of the annulus the valve replacement was performed after decalcification using CUSA. After surgery, she experienced a transient sick sinus syndrome ; however, the overall course was good, and the platelet counts spontaneously recovered. More than 12 months have passed since surgery, but the platelet counts remains around 110,000.

Delayed-Onset Paraplegia after Type A Dissection Repair / 日本心臓血管外科学会雑誌

We present the case of a 53-year-old man who developed delayed-onset paraplegia after type A dissection repair. He was referred to our hospital with a diagnosis of type A dissection, for which we performed total arch replacement. Although the patient started walking on postoperative day 4, on postoperative day 5, he developed lower limb paraplegia without any precipitating episodes. Computed tomography showed that the false lumen was thrombosed in the upper descending thoracic aorta and hypoperfused in the lower descending thoracic aorta. The cerebrospinal fluid was immediately drained to maintain the spinal pressure at 14 cm H₂O for four days. Although the patient began to move his legs immediately after treatment, he remained paraparetic, and was transferred to another rehabilitation hospital on postoperative day 40.

Successful Recovery from Possible Transfusion-Related Acute Lung Injury Following a Redo Aortic Valve Replacement / 日本心臓血管外科学会雑誌

A 73-year-old man who underwent redo aortic valve replacement due to dysfunction of tissue heart valve developed hypoxemia with bilateral infiltrates on frontal chest radiograph and hypotension shortly after his operation. Due to the presence of progressive hypotension and hypoxemia, we inserted an intra-aortic balloon pump and, furthermore, provided percutaneous cardiopulmonary support. We ruled out cardiogenic pulmonary edema based on information from various examinations, including echocardiography, and subsequently diagnosed possible transfusion-related acute lung injury (possible TRALI). The patient was treated by mechanical ventilation and circulatory support under close supervision, showing a trend of improvement from postoperative day 2 and discontinuing mechanical ventilation on postoperative day 11. The patient made an uneventful recovery and was discharged on postoperative day 50. Cardiac surgery patients are at particular risk for TRALI, so physicians should consider TRALI whenever a patient develops hypoxemia during or shortly after transfusion. Rapid diagnosis and appropriate treatment of TRALI are especially important in cardiac surgery patients.

A Surgical Approach for Aortic Valve Replacement in a Patient with a Functional Right Internal Thoracic Artery Graft Located Close to the Posterior of the Sternum / 日本心臓血管外科学会雑誌

A 78-year-old woman who had undergone triple coronary bypass grafting with the right internal thoracic artery (RITA) to the left anterior descending artery 8 years previously was referred to our hospital because of heart failure due to progressive aortic valve stenosis. Coronary angiography showed that all of the coronary grafts were patent, and multidetector-row computed tomography demonstrated the functional RITA graft located close to the posterior of the sternum at the level of the second costal cartilage. To prevent injury of the RITA graft, we initially performed an inverted-L-shaped partial sternotomy extended to the right second intercostal space. After institution of peripheral cardiopulmonary bypass, we performed careful removal of adhesions along the posterior of the sternum under decompressed conditions and accomplished resternotomy safely. The patent internal thoracic artery grafts were never dissected and the patient was cooled to a rectal temperature of 22°C. After aortic crossclamping, myocardial arrest was obtained with systemic hyperkalemia by instilling 40 mEq of potassium chloride into the cardiopulmonary bypass circuit and we successfully performed aortic valve replacement. This method is an alternative approach for re-do cardiac surgery after previous bypass grafting in patients with a functional RITA graft located close to the posterior of the sternum.

Infectious Endocarditis due to Streptococcus bovis with Colon Cancer / 日本心臓血管外科学会雑誌

Infectious endocarditis associated with <i>Streptococcus bovis</i>, which is rare in Japan, is a frequently reported complication of gastrointestinal tumors, especially in colon cancer. We report a patient who was successfully treated for the <i>S. bovis</i>-induced infectious endocarditis complication in colon cancer. A 60-year-old man was admitted to our hospital for detailed examination of high fever of unknown origin, that had lasted for 2 months. <i>S. bovis </i>was identified in the venous blood culture. An echocardiogram showed severe aortic valve regurgitation of the third degree and vegetation on the aortic valve. We therefore diagnosed infectious endocarditis. Colonoscopy revealed sigmoid colon cancer. After endoscopic mucosal resection of the lesion, the aortic valve was replaced. The postoperative course was uneventful and he was discharged from the hospital 36 days post operatively.

Peripheral Pulmonary Artery Aneurysm Secondary to Tricuspid Valve Infective Endocarditis in an Intravenous Drug User / 日本心臓血管外科学会雑誌

We report a case of tricuspid infective endocarditis with peripheral pulmonary artery aneurysm. A 31-year-old man with a history of intravenous drug abuse was admitted to our institution. Echocardiography showed severe tricuspid valve insufficiency and large vegetation (10 mm) attached to the tricuspid valve. Computed tomography (CT) revealed a right peripheral pulmonary artery aneurysm. We operated because of the large amount of vegetation. Before the operation, we performed coil embolization for peripheral pulmonary aneurysm. During the operation, we removed the posterior leaflet with vegetation, and performed tricuspid valve repair. The postoperative course was uneventful. Postoperative echocardiography did not show any tricuspid valve insufficiency or vegetation.

Infectious Endocarditis due to <i>Streptococcus bovis </i>with Colon Cancer / 日本心臓血管外科学会雑誌

Infectious endocarditis associated with <i>Streptococcus bovis</i>, which is rare in Japan, is a frequently reported complication of gastrointestinal tumors, especially in colon cancer. We report a patient who was successfully treated for the <i>S. bovis</i>-induced infectious endocarditis complication in colon cancer. A 60-year-old man was admitted to our hospital for detailed examination of high fever of unknown origin, that had lasted for 2 months. <i>S. bovis </i>was identified in the venous blood culture. An echocardiogram showed severe aortic valve regurgitation of the third degree and vegetation on the aortic valve. We therefore diagnosed infectious endocarditis. Colonoscopy revealed sigmoid colon cancer. After endoscopic mucosal resection of the lesion, the aortic valve was replaced. The postoperative course was uneventful and he was discharged from the hospital 36 days post operatively.

Mid-Term Results of Entry Closure for Chronic Type B Dissecting Aortic Aneurysm / 日本心臓血管外科学会雑誌

We performed entry closure for the chronic type B dissecting aneurysms by open surgical procedure or endovascular stent-graft placement. The purpose of this study is to evaluate the mid-term results of these patients with respect to mortality, morbidity, change of aneurysm diameter and outcome of the false lumen. From 1996 to 2003, entry closure was performed on 8 patients with chronic dissecting aortic aneurysm with an entry site in the descending aorta and visceral arteries that originated from the true lumen. The study population consisted of 4 men and 4 women with a mean age of 63.8±10.9 years. One patient had a DeBakey type III a and 7 patients had a DeBakey type III b dissecting aneurysm. Five patients underwent surgical entry closure and 3 patients underwent endovascular stent-graft placement. The mean follow-up period was 40±29 months. No operative mortalities, complications of paraplegia or visceral ischemia occurred. A leak was identified in 3 patients, 1 patient underwent an open repair with descending aortic replacement and 1 patient required additional stent-grafting. In the follow-up period, 1 patient died of cancer, but there were no dissection-related mortalities or re-operations for increase in size. With the exception of 1 case with a graft replacement, complete thrombosis of the thoracic aortic false lumen was achieved in 6 cases. There were no significant differences in the pre- and postoperative aortic diameter. Overall, complete thrombosis of the thoracic aortic false lumen was achieved with a high rate of success without a dissection-related mortality. Long-term follow-up, however, is necessary because a reduction in size did not occur in some cases.

Clinical Evaluation of SJM Prosthetic Aortic Valve by Doppler Echocardiography: Application of Energy Loss Index (ELI) as a New Index of Aortic Prosthetic Valve Function / 日本心臓血管外科学会雑誌

Although the pressure gradient (PG) and the effective orifice area (EOA) have been used as indices of prosthetic valve function, these values show correctly neither energy loss, nor increased workload. This study aimed to evaluate the prosthetic valve function using echocardiography and PG, EOA and energy loss index, a new index advocated by Garcia et al. These were calculated for 40 patients with aortic prosthetic valve replacement by SJM valve (19HP, 6 cases; 21mm, 16 cases; 23mm, 14 cases; 25mm, 4 cases). Preoperative and postoperative echocardiographic measurements and their variations were analyzed and compared according to the size of implanted valve. In the comparison before and after aortic valve replacement, left ventricular mass (383±151g vs 288±113g, <i>p</i><0.01), SV1+RV5 on ECG (5.07±1.73mV vs 3.83±1.5mV, <i>p</i><0.01), and diastolic left ventricular posterior wall thickness (14.4±3.7mm vs 12.9±2.8mm, <i>p</i><0.05) decreased significantly after the operation. However, there was no significant difference according to the size of the prosthetic valve in these reduction rates caluculated by (preoperative value-postoperative value)/preoperative value. Small size prosthetic valves were used for patients with small diameter of left ventricular outflow tract (LVOT) (19HP, 18±2mm; 21mm, 21±2mm; 23mm, 23±4mm; 25mm, 27±3mm; <i>p</i><0.01) and small body surface area (19HP, 1.5±0.2m²; 21mm, 1.5±0.2m²; 23mm, 1.7±0.1m²; 25mm, 1.8±0.1m²; <i>p</i><0.01) in our study. There was a signifcant difference in EOA (19HP, 1.2±0.4cm²; 21mm, 1.9±0.7cm²; 23mm, 2.2±0.9cm²; 25mm, 3.5±1.1cm²; <i>p</i><0.01), but not in ELI (19HP, 1.01±0.41cm²/m²; 21mm, 1.87±1.03cm²/m²; 23mm, 1.83±1.09cm²/m²; 25mm, 3.08±1.21cm²/m²; <i>p</i>=0.055) according to the size of the prosthetic valve. Small size prosthetic valves had small EOA, but showed satisfactory valve function in decreasing left ventricular hypertrophy and reducing LVM and ELI of small size was similar to that of large size.

Tuberculous Abdominal Aortic Aneurysm. A Case Report / 日本心臓血管外科学会雑誌

A 52-year-old woman who had been treated for miliary pulmonary tuber culosis complained of left flank pain. Abdominal aortic angiography revealed a saccular type aneurysm in the supra-renal abdominal aorta. We resected the aneurysm and reconstructed the aorta by arificial graft patch under partial extracorporeal circulation. The left renal artery was reconstructed by an artificial graft. During the operation, the superior mesenteric artery and the bilateral renal arteries were perfused by blood from the extracorporeal circuit. On pathological examination, it was shown that the aneurysm was caused by tuberculosis.

Renal Function and Hemolysis Associated with Intraoperative Autotransfusion in Abdominal Aortic Surgery / 日本心臓血管外科学会雑誌

Renal function, hemolysis and hematologic parameters after transfusion using a cell-separation (CS) device were retrospectively evaluated during abdominal aortic aneurysm repair. Fifty-eight patients were divided into two groups, that is, the CS group (<i>n</i>=39) who received autologous retransfusion using the CS device and the non-CS group (<i>n</i>=19) who were operated before 1989, when we started to use CS device in our operating theater. Hematologic parameters and levels of GOT, GPT, LDH, BUN and creatinine were assessed before and 1, 2, 3, 4 and 7 days after the operation. Mean transfused homologous blood was 1.3±1.8 units in the CS groups and 4.9±3.1 units in the non-CS group (<i>p</i><0.05). Peak levels of LDH and GPT were significantly higher in the CS group than the non-CS group (<i>p</i><0.05) after the operation (GOT, CS group: 60.4±29.1IU/<i>l</i> vs non-CS group: 34.8±12.3IU/<i>l</i>, LDH, CS group: 643±324IU/<i>l</i> vs non-CS group: 446±108IU/l). There was no significant difference in the levels of BUN and creatinine levels between the two groups. Hemoglobin levels decreased gradually after the operation in CS group patients who did not receive a homologous blood transfusion. These data suggested that mild hemolysis occurred after retransfusion of autologous blood, but that the hemolysis due to the CS device had no effect on the renal function of the patients.

Efficacy of ESP Monitoring during Thoraco-Abdominal Aortic Replacement for Prevention of Intraoperative Spinal Ischemia / 日本心臓血管外科学会雑誌

We evaluated the efficacy of evoked spinal potential (ESP) monitoring during thoracoabdominal aortic replacement to prevent intra-operative spinal ischemia. Nine patients underwent intraoperative ESP monitoring. The ESP was unchanged in 5 patients and decreased in 4 patients. However, ESP recovered in 2 of them by the following techniques: (1) perfusion of intercostal arteries, (2) elevation of distal bypass perfusion pressure, (3) slight hypothermia. Postoperative paraplegia occurred only 1 patient of the 2 whose ESP was not restored. The sensitivity and specificity of the efficacy of ESP monitoring were 100% and 87.5%, respectively. We concluded that ESP is the most useful monitoring for prevention of operative spinal ischemia during thoracoabdominal aortic replacement.