Off-Pump Coronary Artery Bypass Grafting for an Unstable Angina Pectoris Complicated by Heparin-Induced Thrombocytopenia Diagnosed after Introducing Hemodialysis / 日本心臓血管外科学会雑誌

<p>A 53-year-old man was urgently hospitalized with chronic renal failure, congestive heart failure, pulmonary edema, and pneumonia. He received respiratory support and dialysis after hospitalization in the intensive care unit. Coronary arteriography revealed an old myocardial infarction and unstable angina (triple vessel disease). Surgery was planned. However, after dialysis under heparin administration, clot formation was noted in the dialyzer. Serological tests confirmed the presence of antibodies to heparin-platelet factor 4 complex ; accordingly, heparin-induced thrombocytopenia (HIT) was diagnosed. Coronary artery bypass surgery should preferably be performed early in the case of coronary artery disease. However, surgery during the acute phase of HIT when antibodies to heparin-platelet factor 4 complex (HIT antibodies) are present is associated with a very high risk of developing thromboembolism. There is no criterion regarding the optimal timing for surgery when HIT antibodies are present. Therefore, clinicians are often confused about this. In cases where the platelet count, D-dimer level, fibrinogen degradation product (FDP) level, and fibrinogen level improve, thrombin production due to HIT antibodies is thought to decrease. We considered that the improvement in these values suggests that the number of HIT antibodies decreases and thus HIT antibody activity would be reduced. We evaluated the platelet count, D-dimer level, FDP level, and fibrinogen level over time and accordingly determined the optimal timing for surgery. In the present case, argatroban administration was started after HIT developed, and the platelet counts increased gradually ; the D-dimer and FDP levels decreased, whereas there were no significant changes in the fibrinogen levels. Although HIT antibodies were still present, we performed off-pump coronary artery bypass grafting under the administration of argatroban when the platelet count, D-dimer, and FDP values improved. The patency of coronary bypass grafts was confirmed postoperatively ; the patient did not develop thromboembolism during the perioperative period and was discharged without complications. When HIT antibodies are present, an improvement in platelet count, D-dimer, and FDP values is thought to be useful in determining the optimal timing of surgery.</p>

Successful Treatment of a Rapidly-Expanding Infected Thoracic Aortic Aneurysm with <i>Streptococcus pneumonia</i> / 日本心臓血管外科学会雑誌

An 83-year-old woman who had an attack of fever, fatigue, and lumbar pain was hospitalized as an emergency. Detailed investigations revealed that she had urinary infection, infectious spondylitis, and bacteremia with <i>Streptococcus pneumonia</i>, for which she received antimicrobial therapy. After 12 days in hospital, enhanced computed tomography showed that the aortic arch had expanded, with fluid collection. Though there had been no imaging findings by computed tomography scan on admission. We thought this was an infected thoracic aortic aneurysm with <i>Streptococcus pneumonia</i>, and continued to administer the antibiotic drugs for infection control. After 14 days in hospital, she developed hoarseness and complained of severe back pain. Emergency computed tomography scan showed that the aortic arch had further expanded to 66 mm in size and that much more fluid had collected. We decided it was an impending rupture of the rapidly-expanding infected thoracic aortic aneurysm, and we then performed an emergency operation. The infected portion of the thoracic aorta was resected. The ascending, arch, and descending portions of the aorta were replaced with rifampicin-bonded synthetic graft, and then omental wrapping was performed. Antimicrobial administration was continued after surgery. The postoperative course was uneventful. The infection was successfully controlled. She was discharged without complications. No signs of recurrent infection have been observed for 1 year and 6 months after operation.

A Case of Left Ventricular Rupture during Mitral Valve Reconstruction / 日本心臓血管外科学会雑誌

Left ventricular rupture is one of the critical complications that can occur during cardiac surgeries, often during a mitral valve replacement. We report a case in which we encountered a left ventricular rupture during a mitral valve reconstruction after completing use of a cardiopulmonary bypass. A 58-year-old man was found to have a cardiac murmur during a health check-up, and visited a nearby hospital where he was given a diagnosis of severe mitral valve regurgitation due to a prolapsed mitral valve by an echocardiographic examination. Under a median sternotomy, a cardiopulmonary bypass was established, and we reconstructed chordae tendineae with Gore-Tex suture and placed an annuloplasty ring to repair the mitral valve. Weaning from the cardiopulmonary bypass was simple, but bleeding inside the pericardium increased during the following hemostasis and we found an oozing area in the left ventricular posterior wall, which was diagnosed as a left ventricular rupture. The patient was placed back on cardiopulmonary bypass, and we closed the ruptured area by tucking it with felt strips while the heart was beating and reinforced it with a fibrin sheet, PGA sheet, and fibrin glue. We then inserted IABP. The hemodynamic condition was stable afterwards and IABP was removed on the 7th day. The patient developed an atrial flutter on the 13th day, which was drug resistant, and we performed a radiofrequency ablation. The patient fully recovered and was discharged on the 44th postoperative day. Considering factors such as excess resection of papillary muscle, failure of mitral loop due to a resection of papillary muscle, excess resection of annulus tissue, excess traction of papillary muscle, damage to the left ventricular inner wall by suction tubes, or excess load on the left ventricle when removing a cardiopulmonary bypass as possible causes, we think very careful maneuvers are required and important even in a mitral valve reconstruction.

Preoperative Assessment of Small Saphenous-Type Varicose Veins by Three-Dimensional CT Venography with Dual-Route Injection / 日本心臓血管外科学会雑誌

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.

Aortobronchopulmonary Fistula Caused by a Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

Aortobronchopulmonary fistula (ABPF) caused by thoracic aortic aneurysm is uniformly fatal if not treated surgically. Here we report 12 cases, and discuss the cause, surgical treatment, and results. Between 1993 and 1998, we encountered 12 cases of ABPF. ABPFs were complicated by (A) true aneurysms without infection (<i>n</i>=4), (B) aortic dissection (<i>n</i>=1), and (C) infective pseudoaneurysms occurring after thoracic aortic surgery (<i>n</i>=4). Three patients refused surgery. The ABPFs were located in the ascending aorta to the trachea (<i>n</i>=1), the distal arch to the upper lobe of the left lung (<i>n</i>=6), and the descending aorta to the lower lobe (<i>n</i>=5). They were repaired by graft replacement or patch closure. All four patients in group A have shown an uneventful course 10 patient-years after surgery. One patient in group B died of mediastinitis. The other three patients in group B were discharged from hospital, but died of sudden recurrent hemoptysis at their homes. A patient with aortic dissection underwent patch closure of an ABPF located at the distal arch, however he died of recurrent hemoptysis due to bleeding from another ABPF at the descending aorta. All of the three patients who refused surgery died of hemoptysis at various times after diagnosis. The surgical results in the non-infection group (A) were satisfactory. The group with infection (C) showed poor results after surgery and died due to recurrence of hemoptysis caused by new ABPFs arising from infected pseudoaneurysms. ABPF caused by aortic dissection (B) is difficult to repair because of severe adhesions to the lung and the unclear location of the fistula. ABPF infection is difficult to control after thoracic surgery and it is the reason for the fatal outcomes, due mainly to sudden hemoptysis. Early diagnosis and prompt surgical intervention are important for patients with ABPF.

Long-Term Results of Surgery for Stanford Type A Aortic Dissection. Risk Factors of Distal False Lumen Dilatation / 日本心臓血管外科学会雑誌

For treatment of Stanford type A aortic dissection, we have operated only on the ascending aorta out of consideration of operative invasions and complications. However, if only the ascending aorta is replaced, the residual distal false lumen and its dilatation become problematic. We examined the risks of postoperative dilatation of the distal false lumen in terms of the following three factors (1) patency of the distal false lumen, (2) Marfan's syndrome, (3) aortic medial degeneration. Between 1984 and 1993, 55 cases of acute and chronic type A aortic dissection were treated surgically at our hospital, and a total of 33 survivors were subsequently followed up. The mean follow-up period was 92 months. None of the survivors died of late aortic complications. Five patients (15%) had Marfan's syndrome. As a result, all 18 patients (55%) with a closed distal false lumen did not show late distal dilatation or late deaths. Marfan patients had a high incidence of distal dilatation of the aorta and required additional aortic operations. Aortic medial degeneration was a high risk factor for younger onset (>40 years old) of aortic dissection, patent false lumen, and late dilatation, not only for Marfan patients but for non-Marfan patients. Non-Marfan patients with onset of aortic dissection under 40 years of age, showed significantly high incidence of medial degeneration. In conclusion, patent false lumen and medial degeneration of non-Marfan patients is a high risk factor of late dilatation as well as those of Marfan patients. On the other hand, patent false lumen is not a risk factor of late dilatation for non-Marfan patients without medial degeneration. Therefore, in both Marfan and non-Marfan patients with onset under 40 years of age, concomitant aortic arch repair should be performed because the rate of reoperation is significantly high.

Isolated Tricuspid Regurgitation Caused by a Severely Dilated Tricuspid Annulus / 日本心臓血管外科学会雑誌

Isolated tricuspid regurgitation is extremely rare, and in most of the previously reported cases, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case, a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course.

Pseudocoarctation of the Aorta Complicated by Distal Arch Aortic Aneurysm Coexistent with Aberrant Right Subclavian Artery A Successfully Operated Case / 日本心臓血管外科学会雑誌

A 22-year-old woman with pseudocoarctation of the aorta as a complication of disal arch aortic aneurysm and aberrant right subclavian artery was successfully treated. She was the elder of identical twins, with a past history of spontaneous closure of the ventricular septal defect. Preoperative angiograms suggested pseudocoarctation of the aorta complicated by distal arch aortic aneurysm with aberrant right subclavian artery. At operation, the distal arch was replaced with a 14mm woven dacron graft and the left subclavian artery was reconstructed by interposition of 6mm IMPRA graft between the vessel and ascending aorta. The postoperative angiograms indicated successful reconstructions. Contrast-enhanced CT scans of the younger identical twin showed no anomaly of the thoracic aorta.

One-Stage Operation of Annulo Aortic Ectasia Complicated with Acute Aortic Dissection of Stanford Type B / 日本心臓血管外科学会雑誌

A 51-year-old man was admitted with symptoms of sudden back pain and abdominal pain. Echocardiography and aortagraphy demonstrated enlargement of the aortic annulus, aortic regurgitation and Stanford type B aortic dissection. Since an entry of the aortic dissection was located at the root of the left subclavian artery, a one-stage operation consisting of aortic root replacement and total arch replacement was scheduled. The aortic root replacement using Piehler's modification was first performed followed by total arch replacement combining with the closure of the entry in the distal aortic arch was followed under selective cerebral perfusion. All procedures were complished through median sternotomy. The postoperative course was uneventful and aortography showed good reconstruction of the coronary arteries and the cervical arteries and thrombo-exclusion of the false lumen in the descending aorta. This method was useful for in this case of annulo aortic ectasia with Stanford type B aortic dissection.

One-Staged Operation for Juxtarenal Aortic Occlusion and Myocardial Infarction / 日本心臓血管外科学会雑誌

A 59-year-old male suffered dyspnea and ischemia of the lower limbs due to myocardial infarction (occlusion of the right coronary artery and 99% stenosis with delay in the left anterior descending artery) and juxtarenal aortic occlusion, respectively. Juxtarenal aorto-femoral bypass operation using a Y-shaped prosthesis and coronary arterial bypass grafting using the left internal thoracic artery (LITA) and right gastroepiploic artery (RGEA) were performed simultaneously. As the left internal thoracic artery was the route of collateral blood flow to the left lower limb, aorto-femoral bypass was initially made prior to aorto-coronary bypass operation. Because of complete obstruction of the abdominal aorta and juxtarenal lumbar arteries, neither hemodynamic changes nor bleeding occurred during the reconstruction of the abdominal aortic occlusion in spite of severe coronary disease. This procedure was useful for protection of limb ischemia and shortage of extracorporeal circulation time, in addition to producing a route for insertion of an intraaortic balloon pumping catheter.