Hemodiafiltration during Off-Pump Coronary Artery Bypass Grafting for a Chronic Dialysis Patient / 日本心臓血管外科学会雑誌

Patients on chronic hemodialysis, undergoing coronary artery bypass grafting (CABG) have high perioperative mortality and morbidity. In order to reduce the perioperative risks, we performed intraoperative hemodiafiltration (HDF) during off-pump CABG (OPCAB). A 62 year-old-man, who had been on dialysis for 2 years, was admitted with a sensation of chest compression. A coronary angiography revealed 75% stenosis with severe calcification in the left anterior descending artery and 90% stenosis in the second diagonal branch. During the operation, veno-venous HDF was started, using a double lumen catheter that was introduced into the femoral vein at the same time that a skin incision was made. During the exposure of the diagonal branch by rotating the heart, the blood flow of HDF was decreased and dehydration was halted to avoid hemodynamic deterioration. The patient was extubated 1.5h after the operation and did not require continuous hemodiafiltration (CHDF) in the intensive care unit (ICU). Routine hemodialysis was restarted on the 3rd postoperative day. The postoperative course was uneventful, and the patient was discharged to home on the 11th postoperative day. HDF during OPCAB for this chronic dialysis patient was observed to be effective and yielded an excellent postoperative recovery without CHDF in the ICU.

Autotransplantation and Concomitant Pneunectomy for an Intracardiac Metastatic Lesion and Primary Pulmonary Blastoma of the Left Lung / 日本心臓血管外科学会雑誌

Pulmonary blastoma is rare and its prognosis very poor. A 6-year-old boy was referred to our hospital with chest pain. Computed tomography demonstrated that the left pleural cavity was filled with a tumor. Cardiac echocardiography demonstrated that the tumor had invaded through the pulmonary vein into the left atrium and that the tumor extended into the left ventricle. Part of the tumor was adhered to the anterior leaflet of the mitral valve. To increase operative radicality, an autotransplantation technique was performed concomitantly with resection of the original lesion. Through a median sternotomy, a moderate hypothermic cardiopulmonary bypass was established to obtain cardiac arrest. First, longitudinal incision of right-sided of the left atrium was made. The tumor invaded into the left atrium through the left superior pulmonary orifice. The ascending aorta, the main pulmonary artery, and both caval veins were transected. The left atrium was incised along the pulmonary venous orifices. The heart was completely removed from the mediastinum and transferred to another table. Resection of the intracardiac metastatic lesion and mitral valve replacement was accomplished. During this time, thoracic surgeons performed a left pneunectomy. The left atrial wall around the left pulmonary venous orifices was resected in combination with the left lung. After the deficit of the left atrial wall was repaired with a Gore-Tex patch, the heart was replaced and we reconstructed the great arteries and caval veins. The autotransplantation technique is a useful procedure for combined lesions of the heart and lung.

Successful Surgical Treatment of Thoracic Aortic Aneurysm in Two Patients with Old Cerebral Infarcts and Severely Stenotic Cerebral Vessels / 日本心臓血管外科学会雑誌

Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.

A Successful Case of Sutureless Pulmonary Artery Plasty Using Autologous Tissue for Severe Pulmonary Stenosis after a Rastelli Operation / 日本心臓血管外科学会雑誌

An 11-year-old boy, who underwent a Rastelli operation using a 14mm artificial graft and left pulmonary artery (PA) plasty with an autologous pericardium patch 7 years previously, had severe recurrent left pulmonary stenosis. Reoperation was performed including right ventricular outflow tract reconstruction and left PA plasty. The PA at the most stenotic site was only 2mm in diameter; it was enlarged to 10mm by good exposure and an incision on the pulmonary intima. A bovine pericardium patch with a handmade ePTFE valve was sutured onto the autologous tissue not onto the pulmonary intima to avoid restenosis and in expectation of the growth of the pulmonary orifice. On postoperative 3-D CT, the left pulmonary artery was patent and 9mm in diameter. Pulmonary scintigraphy showed an improvement in the left pulmonary perfusion. This sutureless technique was useful in this case of severe pulmonary stenosis.

Retrograde Cerebral Perfusion Using a New Double-Lumen Balloon Catheter via Internal Jugular Vein Cannulation / 日本心臓血管外科学会雑誌

We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

Rupture of the Thoracic Aortic Aneurysm in the Course of Corticosteroid Therapy for Rheumatic Interstitial Pneumonitis / 日本心臓血管外科学会雑誌

Rheumatoid arthritis and interstitial pneumonitis were diagnosed in a 72-year-old man and thoracic computed tomography revealed an aortic arch aneurysm 50mm in diameter. Steroid therapy gave symptomatic relief and improved laboratory findings, but hyperglycemia and hypertension developed. Two months later the thoracic aneurysm ruptured, and computed tomography revealed expansion of the aneurysm to 60mm in diameter and surrounding hematoma. Emergency total arch replacement was performed successfully with deep hypothermic cardiopulmonary bypass and selective cerebral perfusion. The steroid therapy was considered to be responsible for the rapid expansion and rupture of the thoracic aneurysm. When prescribing steroids for a patient who has a concomitant atherosclerotic cardiovascular disease, we should not only control the steroidal side effects strictly, but also carefully watch the course of the atherosclerotic lesion.

A Successful Case of Conccmitant Aortic Valve Replacement Using an Intravalvular Implantation Technique and Coronary Artery Bypass Grafting in Aortitis Syndrome / 日本心臓血管外科学会雑誌

Aortitis syndrome is a disease of non-specific inflammation of the arterial wall which produces necrosis and fibrosis of the intima. Indications, timing, and the choice of operative procedures should be determined carefully because of its complex pathology. We encountered a patient with combined aortic valve incompetence and left main coronary artery stenosis due to aortitis syndrome. The patient received adequate steroid therapy and the inflammatory reaction was well controlled before surgery. The patient underwent concomitant aortic valve replacement using an intravalvular implantation technique and coronary artery bypass grafting. The hospital course of the patient was uneventful. Neither paravalvular leakage nor inflammatory recurrence was observed during 18 months of follow-up.

A Case of Primary Cardiac Lymphoma Diagnosed by Open Biopsy with Median Sternotomy / 日本心臓血管外科学会雑誌

An 60-year-old man who initially presented with ventricular tachycardia was suspected of cardiac tumor because of localised hypertrophy of the right ventricle. Although the localized region detected by an echocardiography suggested malignancy, percutaneous transcatheter myocardial biopsy failed to obtain a histological diagnosis. Six months later, a permanent pace maker was implanted due to complete AV block. Two years after the first admission, echocardiogram and computed tomography demonstrated a cardiac tumor in the right ventricle. To obtain a histological diagnosis, open biopsy was performed under median sternotomy and showed malignant lymphoma. Antemortem diagnosis of cardiac malignancy is usually very difficult. Median sternotomy is an established procedure for cardiovascular surgeons. Open biopsy can be an acceptable technique to obtain histological diagnosis of the neoplastic region in terms of safety and simplicity, and has good sampling accuracy compared with other diagnostic modalities. We recommend early stage surgical exploration when cardiac malignancy is a diagnostic possibility.

A Classification of Consumption Coagulopathy Associated with Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Fifty consecutive patients who underwent elective repair for abdominal aortic aneurysms were preoperatively evaluated on blood coagulation tests and retrospectively classified into three groups. Class I had a normal profile on the tests. Class II had either high FDP (≥20ng/ml), TAT (≥20ng/ml), or positive results on the FM test. Class III had either thrombocytopenia (≤120/μl) or bleeding symptoms with Class II conditions. Operative mortality was 0% (0/26) in Class I, 13% (2/15) in Class II, and 22% (2/9) in Class III patients. This classification is considered to be simple and useful to assess specific coagulopathy for aortic aneurysms.

Progressive Heart Failure on Long after Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy / 日本心臓血管外科学会雑誌

The 37-year-old woman underwent mitral valve replacement (MVR) with a Carpentier-Edwards bioprosthesis for hypertrophic obstructive cardiomyopathy (HOCM) 14 years previously. Since the 10th postoperative year, progressive right heart failure due to tricuspid valve regurgitation was recognized. Therefore, reoperation was recommended. At the time of reoperation in the 14th postoperative year, the cavity of the left ventricle was markedly diminished. In particular, deformitiy of the right ventricle was found. This was considered to be the effect of progressive septal hypertrophy. The mitral valve was replaced with a 25mm Carpentier-Edwards and the tricuspid valve with a 31mm Carpentier-Edwards bioprosthesis. Although the weaning from the cardiopulmonary bypass was uneventful, postoperative right heart failure occured with hyperbilirubinemia followed by multiple organ failure. She died on the 47th postoperative day. At autopsy, the intraventricular septal thickness was 24mm and the cavities of left and right ventricle were almost occluded by septal hypertrophy. This is considered to be a rare case of long-term survival after MVR in a patient with HOCM.

A Case Report of Left Ventricular Rupture Following Mitral Valve Replacement. Site of Rupture Determined by Pathologic Examination / 日本心臓血管外科学会雑誌

A 60 year-old female underwent mitral valve replacement with a Duromedics valve. She was in good condition during weaning from cardiopulumonary bypass. However, rupture of the left ventricle was manifested by massive bleeding just after dis-contination of cardiopulmonary bypass. A large hematoma accompanied by bleeding was observed in the posterior atrio-ventricular groove. The patient was quickly put back on total cardiopulmonary bypass. A slight laceration was suspected in the membranous portion of the ventricular septum just below the mitral annulus. Re-valve replacement was performed by reinforcing the mitral annulus with a Dacron patch. This patient was removed from cardiopulmonary bypass, but died of multiple organ failure in 7 days after operation. At autopsy, the left ventricular rapture was identified just below annuls in the area of the atrioventricular groove. Furthermore, extensive hematoma was noted in the posterior atrioventricular groove.

New Retrograde Coronary Sinus Perfusion Catheter without Requiring Right Atriotomy / 日本心臓血管外科学会雑誌

The current technique of retrograde coronary sinus perfusion (RCSP) has been provided double cannulation of the vanae cavae and isolation of these vessels, and right atriotomy. Most aortic valve and coronary artery bypass surgery are performed with single venous cannulation. We used a new RCSP catheter, Retroplegia (Research Medical Co.), and performed Cabrol procedure safely with single venous cannulation. This catheter can be cannulated to the coronary sinus through a right atrial purse-string suture without opening the right atrium. The occlusion balloon is inflated spontaneously by infusing the cardioplegic solution and occlude the coronary sinus adequately and nicely. This catheter has double lumen, one is for infusion of the cardioplegic solution, the other is for measurement of the coronary sinus pressure. We believe that this catheter is useful for RCSP of the cardiac surgery using single venous cannulation.

A Case of Recurred Left Ventricular Myxoma / 日本心臓血管外科学会雑誌

Myxoma of the left ventricle is exceedingly rare and to the best of our knowledge not a single case of its recurrence has been reported in Japan. We have recently experienced a case in which a myxomatous tumor of the left ventricle recurred at the same site as the primary lesion 2.5 years after operation and was treated by surgical excision. The patient was a 28-year-old female who, under the diagnosis of myxoma of the left ventricle, underwent surgical removal of the tumor and mitral valve replacement at her age of 25 years. Although her postoperative course was uneventful, she was noticed, at her age of 28 years, of her inaudible prosthetic valve clicks on auscultation at the outpatient service. Echocardiography revealed a tumor mass in the left ventricle, which tended to grow with the elapse of time. Echocardiography on rehospitalization disclosed a mobile cystic tumor on the posterior wall of the left ventricle, while pulmonary arteriography also revealed a movable tumor in the left ventricle. Intraoperatively, there was noted a solid tumor, composed partly of cystic structure, on the posterior wall of the left ventricle and quick pathology led to a suspected diagnosis of myxoma. Since the tumor was found to have involved the ventricular septum and myocardial tissue of the posterior wall of the left ventricle, its complete surgical excision was impossible. The tumor, with its growth pattern and morphology, was diagnosed as a malignant clinical behavior one, although histopathological evidence indicates its benignancy.