A Case of One-Stage Surgical Treatment for Chronic Mesenteric Ischemia Associated with Severe Aortic Valve Regurgitation and Stenosis / 日本心臓血管外科学会雑誌

<p>We report a case of chronic mesenteric ischemia associated with severe aortic valve regurgitation and stenosis (ASR). The patient was a 76-year-old man who had been given a diagnosis of ASR in his 40s. He gradually developed heart failure and chronic kidney disorder due to deterioration of ASR. He had started hemodialysis 1 year before admission and had complained of abdominal pain after meals and weight loss during that period. He was admitted to the Department of Cardiology in our hospital for evaluation of ASR. Severe ASR with low output syndrome (C. I. 2.00 L/min/m²) were confirmed by cardiac catheter examination. In addition, abdominal angiography revealed total occlusion of the superior mesenteric artery (SMA) and severe stenosis of the celiac artery (CA). We considered that low cardiac output due to severe ASR had exacerbated the mesenteric ischemia. We performed AVR and abdominal aorta-SMA bypass at the same time to prevent acute mesenteric ischemia in the perioperative period. The combination of valvular disease and CMI is very rare. This is the first report in Japan of simultaneous valve replacement and mesenteric artery revascularization.</p>

Infected Abdominal Aortic Aneurysm with a Previous History of Coronary Artery Bypass Grafting with the Right Gastroepiploic Artery / 日本心臓血管外科学会雑誌

We report a case of successful anatomical reconstruction with omentopexy of an infected abdominal aortic aneurysm (AAA) in a patient with a previous history of coronary artery bypass grafting with the right gastroepiploic artery. A 60-year-old man was referred to our institute because of fever and abdominal pain during hemodialysis for chronic renal failure. Antibiotic therapy was started after computed tomography revealed an infected abdominal aortic aneurysm. After infection control, surgical treatment was scheduled. At surgery, left axillo-bifemoral bypass was performed first, because it was unclear whether the omentum was large enough for omentopexy. At laparotomy, adequate omentum and infective AAA were confirmed. AAA repair using a rifampicin-soaked graft, and omentopexy were performed. <i>Enterobacter aerogenes </i>was detected from the resected aortic wall. After the operation, intravenous antibiotic was used for 25 days until CRP was normalized. One year follow-up showed no sign of re-infection.

A Case of Type A Acute Aortic Dissection in an Elderly Woman with Immune Thrombocytopenia Who Underwent Replacement of the Ascending Aorta and Aortic Arch and Later Required Aortic Root Replacement for Redissection of the Aortic Root / 日本心臓血管外科学会雑誌

We report a case of type A acute aortic dissection in an elderly woman with immune thrombocytopenia (ITP) who underwent replacement of the ascending aorta and aortic arch and later required aortic root replacement for redissection of the aortic root one month after her initial surgery. She was an 86-year-old woman with severe mitral regurgitation, and surgery was contraindicated because of her age and ITP. In October 2014, the patient presented with back pain. Computed tomography confirmed the diagnosis of her condition as type A acute aortic dissection, and she was immediately transferred to our hospital. Because echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and moderate tricuspid regurgitation, we performed replacement of the ascending aorta and aortic arch, mitral valve repair, and tricuspid annuloplasty. We used Bioglue to fuse the false lumen of the type A acute aortic dissection and used a Teflon felt sandwich for the proximal anastomosis technique. Respiratory support was discontinued 91 h after her first operation ; however, 30 days after surgery, she developed a to-and-fro murmur-a sign of the progression of heart failure. Echocardiography showed aggravation of aortic regurgitation, and computed tomography showed aortic root redissection ; therefore, 39 days after the initial surgery, we performed aortic root replacement. During the operation, we found the entry under the proximal anastomosis with an almost semicircle form at the right coronary cusp to the noncoronary cusp, and the dissection extended close to the right coronary artery ; thus, we performed bypass to the right coronary artery. Pathologic findings did not establish a causal association between the redissection and Bioglue, and we believed the fragility of the tissue and the selection of the surgical procedure to be the cause of redissection. The patient was transferred to another hospital when she was able to walk and eat, which was 121 days after her first operation. The patient required 50 units of platelet transfusion during her first and second operations, but her bleeding was easily controlled during surgery. She needed two procedures of pericardium drainage for pericardiac effusion and cardiac tamponade, which may relate to ITP. The diagnosis of redissection of the aortic root was made 30 days after the patient's first operation, on the basis of exacerbation of the to-and-fro murmur. Here, we emphasize the clinical importance of basic observations over time, such as auscultation, that are liable to be overlooked in the intensive care unit.

Chronic Aortic Dissection with Aorta-Right Atrium Fistula / 日本心臓血管外科学会雑誌

Aortic dissection with rupture into the right atrium is an extremely rare and rapidly fatal condition. We report the case of a 59-year-old man with a history of double valve replacement 2 years earlier at another hospital. Although the previous postoperative course had been uneventful, the patient had experienced facial edema and general fatigue for 10 days before admission to our hospital because of heart failure. The diagnosis of chronic aortic dissection with rupture into the right atrium was confirmed by intraoperative transesophageal echocardiography. At operation, we observed an aortic dissection that originated from a tear in the original aortic incision line. The fistula extended from the false lumen to the right atrium. The aortic adventitia were partially defective. The aortic dissection had ruptured and a pseudo-aneurysm had formed. We performed ascending aortic replacement and closure of the aorta-right atrium fistula under hypothermic arrest on cardiopulmonary bypass. The postoperative course was uneventful and the patient was discharged on the 17th postoperative day.

Hybrid Treatment of the Intrathoracic Right Subclavian Artery Aneurysm / 日本心臓血管外科学会雑誌

Subclavian artery aneurysm (SCAA), a peripheral arterial aneurysm, is a rare entity. The surgical procedure and approach depend on the location of the aneurysm. We present a case of the endovascular therapy combined with cross axillary bypass. The patient was a 75-year-old man with a small abdominal aortic aneurysm. Multi-detector computed tomography (MDCT) revealed an intrathoracic right SCAA 38 mm in diameter. The operation was performed successfully under general anesthesia. After cross bypass of bilateral axillary artery, the orifice of the right subclavian artery was covered with a stent-graft inserted into the right common carotid artery-brachiocephalic artery and the right subclavian artery was occluded with coils distal to the aneurysm. Post operation angiogram showed complete exclusion of the SCAA and patency of the right common carotid and right vertebral artery. We thought this hybrid treatment for the intrathoracic SCAA could be a useful surgical strategy.

Development of a Pseudoaneurysm of the Thoracic Aorta at the Cannulation Site : Our Experience with Three Cases / 日本心臓血管外科学会雑誌

A pseudoaneurysm of the thoracic aorta after cardiac surgery is a rare complication, but can be life-threatening when it is ruptured. The pseudoaneurysm itself presents no symptoms in many cases, or may be similar to an atherosclerotic aortic aneurysm. Therefore, it is usually found incidently during imaging studies. We encountered 3 cases of pseudoaneurysm of the thoracic aorta that developed during the long-term follow-up after congenital cardiac surgery. None of the patients experienced specific symptoms associated with the pseudoaneurysm, and were diagnosed by chest roentgenograms and computed tomography. Most patients who undergo surgery for congenital heart defects as adolescents are free from medical treatment, and do not regularly see a doctor after the surgery. It is important to consider the possibility of a pseudoaneurysm in patients having a history of cardiac surgery.

Stanford Type A Acute Aortic Dissection Case Caused by Blunt Chest Trauma / 日本心臓血管外科学会雑誌

A 31-year-old man fell into syncope caused by compression by a machine in his factory. He was taken to the nearest hospital at once for treatment. His chest X-ray seemed normal and his general condition improved. He received no medical treatment and was allowed to return home. Two days later, he went to the hospital for further investigation, and contrast-enhanced chest computed tomography (CT) was performed. Chest CT showed aortic dissection from the ascending aorta to the aortic arch. Therefore, he was admitted for bed rest with antihypertensive therapy. He was discharged on the 35th day after the accident. However, the diameter of the ascending aorta was found to have become dilated, and so he underwent ascending aorta and hemiarch replacement at our hospital. His postoperative course was uneventful, and he was discharged on the 16th postoperative day. We report a rare case of an acute aortic dissection caused by blunt chest trauma.

A Case of Acute Retrograde Aortic Dissection during TALENT Endovascular Repair of a Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

An 83-year-old woman underwent stent graft endovascular repair using a Medtronic TALENT device for a saccular aortic aneurysm in the distal arch. The landing zone which targeted the proximal side was directly distal to the orifice of the left common carotid artery (Z2), and the stent graft was placed at the targeted position. However, a decline in the right radial arterial pressure was observed immediately following this, and a retrograde dissected ascending aorta was observed on a transesophageal echocardiogram. The endovascular surgery was immediately converted to open surgery, and an intimal tear to the lesser curvature of the arch, caused by a bare spring (bare stent) of the proximal stent graft, was observed. Total arch replacement was performed by means of the concomitant use of the placed stent graft. Sometimes a TALENT stent graft exhibits specific movements (e.g. a misaligned opening) on its initial deployment. It is therefore believed that special attention is necessary when placing it in the aortic arch.

Familial Aortic Dissection: A Report of Four Cases in Two Families / 日本心臓血管外科学会雑誌

There are rare reports of families with multiple members with aortic dissection in the absence of Marfan syndrome. We encountered four cases of aortic dissection in two families. The aortic dissection occurred in the mother and child of the first family and in sisters of the second family. All cases had systemic hypertension preoperatively and presented Stanford type A aortic dissection. All of them were operated successfully. None of them showed the characteristics of connective tissue disease affecting the skeletal, ocular, and cardiovascular system. However, many members of the two families had systemic hypertension and histopathological examination of the aorta showed cystic medial necrosis in all of the four cases. The present study suggests that the familial aortic dissection may be caused by weakness of the aortic wall related to heredity and systemic hypertension.

A Case of Unruptured Aneurysm of the Sinus of Valsalva / 日本心臓血管外科学会雑誌

A 36-year-old woman was admitted because of dyspnea on exertion and palpitations, during follow-up for ventricular septal defect since age 5. Physical examination revealed a grade IV/VI ejection systolic murmur at the second left intercostal space. Echocardiogram failed to recognize an unruptured aneurysm of the sinus of Valsalva protruding into the right ventricle which was seen on right ventriculogram (type I of Konno). Surgical treatment was successfully performed. Right ventriculography was much more effective rather than echocardiography in this case.

A Case of Ischemic Limb Perfusion during Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

A 64-year-old woman with chest pain and intermittent claudication was admitted to our hospital. Unstable angina pectoris and arteriosclerosis obliterans (ASO) of both leg were diagnosed. Angiography indicated total occlusion of the right external iliac artery and severe stenosis of the left external iliac artery, in addition to significant stenoses of the three major coronary arteries. The ankle pressure index was 0.49 in her right leg, and 0.74 in the left. Because coronary stenting was unsuccessful, emergency coronary artery bypass grafting was performed prior to arterial reconstruction of the lower extremities. To prevent exacerbation of limb ischemia during cardiopulmonary bypass (CPB), selective limb perfusion was performed with a 14-gauge intravenous catheter inserted into the right superficial femoral artery. There were no complications related to limb ischemia during or after the operation. Selective limb perfusion was considered to be useful to prevent limb ischemia during CPB in patients with ASO of the legs.