Thoracic Endovascular Aortic Repair Following Axillo-Femoral Bypass in a Patient with Stanford B Acute Aortic Dissection Accompanied by Renal Ischemia / 日本心臓血管外科学会雑誌

A 71-year-old male was admitted to our institution because of right leg pain and paleness, accompanied by sudden chest-back pain. The right femoral artery was not palpable. The reticulated cyanosis appeared on the right leg. Contrast enhanced computed tomography (CT) revealed an acute type B aortic dissection (TBAD) extending from the descending thoracic aorta to the left common iliac artery and right external iliac artery. The intimal tear was located at thoraco-abdominal aorta. There was a severe stenosis of the true lumen at bilateral common iliac arteries because of the dynamic compression caused by the extended false lumen. Blood to the right leg was not supplied from the dissected iliac artery, the peripheral circulation was maintained by collateral flow. The patient was diagnosed acute TBAD complicated with lower limb ischemia. An emergent right axillary artery-bifemoral arteries bypass was carried out for malperfusion of lower extremities. The symptoms in the lower limbs disappeared immediately. The bilateral femoral arteries were well palpated. However, 4 days later, uncontrollable severe hypertension and anuria appeared suddenly. Contrast enhanced CT revealed the stenosis of true lumen at bilateral renal arteries and an exacerbation of stenosis of true lumen at abdominal aorta. Emergent thoracic endovascular aortic repair (TEVAR) for entry closure was performed to improve the renal function and prevent mesenteric ischemia. Postoperative contrast enhanced CT revealed the complete closure of the entry tear and dilatation of the true lumen at the descending and abdominal aorta. At the bilateral renal arteries, the blood flow improved. The renal function recovered and mesenteric ischemia did not occurred. In this report, we presented a case of acute TBAD complicated with lower limbs ischemia and late onset acute ischemic renal failure. We first performed the right axillary artery-bifemoral arteries bypass grafting, after that we had to perform TEVAR to close the entry tear. One-stage emergent TEVAR should be considered for acute TBAD with the dynamic compression at the level of abdominal aorta in future.

OPCAB after Placement of Drug-Eluting Stent : A Case of Cardiac Tamponade Developing after Resumption of Ticlopidine Administration in the Early Postoperative Period / 日本心臓血管外科学会雑誌

A 72-year-old man presented with a chief complaint of chest pain. Since ECG showed ST elevation in leads III and _aV_F, suggestive of acute myocardial infarction, we performed emergency coronary angiography which revealed total occlusion of RCA#3, 75% stenosis of LAD#6, and 99% stenosis of LAD#7. Thus, RCA occlusion was the likely cause of the chest pain, and a drug-eluting stent (DES) was placed in RCA#3. OPCAB of the LITA to the LAD (LITA-LAD) was performed 44 days later. The volume of postoperative drainage was very low, and, since the DES was in place, the administration of aspirin 100 mg once daily and ticlopidine 200 mg twice daily was started on the first morning after surgery. On the second morning after surgery, the CVP rose rapidly to 16, and then to 23 mmHg. Chest CT revealed massive hemopericardium and hemomediastinum, and re-thoracotomy was performed for hematoma removal. There was no bleeding at the anastomosis or graft sites, with minimal bleeding from mediastinal adipose tissue. Thereafter, his condition improved uneventfully, and he was discharged on the 19th postoperative day. Since the DES was in place, the administration of antiplatelet agents was resumed in the early postoperative period to prevent occlusion, which resulted in the development of cardiac tamponade due to bleeding. We report the case of severe postoperative complication due to DES placement.

A Case of Left Ventricular Plasty (SAVE Operation) for a Ventricular Septal Perforation and a Left Ventricular Aneurysm Associated with Acute Myocardial Infarction / 日本心臓血管外科学会雑誌

A 71-year-old man with obstruction of the left anterior descending branch (#7) suffered an acute myocardial infarction. A ventricular septal perforation (VSP) and a widespread left ventricular aneurysm were detected in the anteroseptal region by both cardiac ultrasonography and cardiac catheterization. Surgery was performed at week 7 after onset. After establishing extracorporeal circulation, the left ventricular aneurysm was longitudinally excised from the left side of the left anterior descending branch while the patient was maintained in a state of cardiac arrest. A septal anterior ventricular exclusion (SAVE) operation was performed using oblong equine pericardial patches to exclude the left ventricular aneurysm and the VSP portion. The VSP was directly closed with sutures because the surrounding tissues were relatively strong at week 7 after the onset of the myocardial infarction and the portion was excluded with an equine pericardial patch. At the same time, CABG (LITA-LAD) was also performed. After surgery, left ventriculography found no residual shunts and we were able to obtain both a good morphology and satisfactory functioning of the left ventricle. The present method is thus considered to be an effective surgical method that excludes both the VSP portion and the infracted portion, while improving the morphology of the left ventricle for VSP with a left ventricular aneurysm.

Less Invasive Aortic Valve Replacement Following Coronary Artery Bypass Grafting Using the Internal Thoracic Artery: Usefulness of Balloon Occlusion of the Internal Thoracic Artery Graft / 日本心臓血管外科学会雑誌

When performing aortic valve replacement (AVR) in patients with a past history of coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA), the patent ITA graft needs to be detached from the surrounding tissue and occluded to properly protect the myocardium. However, detaching the ITA graft from the surrounding tissue takes time, and caution must be exercised to avoid damaging the graft. Two patients with a past history of CABG using the ITA were scheduled to undergo AVR. To simplify AVR, a balloon was placed preoperatively, and was inflated during aortic occlusion to occlude the ITA graft. The myocardium was adequately protected in this manner. Furthermore, since adhesion detachment was limited to around the ascending aorta, operative duration was short and bleeding volume was low. Balloon occlusion of the ITA graft appears to be useful in reducing the invasiveness of AVR in patients with a past history of CABG.

Aortic Valve Re-Replacement with Aortic Root Enlargement for Aortic Valvular Stenosis after Aortic Valve Implantation with a Freestyle Stentless Porcine Valve / 日本心臓血管外科学会雑誌

We present a successfully treated case of re-operation for aortic valvular stenosis caused by implantation of a stentless prosthesis using oversizing sub-coronary insertion in a young woman. The 17-year-old Japanese woman received aortic valve replacement (AVR) with a 21mm Freestyle stentless porcine valve (Medtronic Inc.), using the oversizing modified sub-coronary insertion because of infectious endocarditis 12 years previously at another hospital. Just after the operation, she suffered severe heart failure. At 16 years old, since a cardiac murmur and dyspnea on effort appeared, and she presented severe heart failure due to significant aortic valvular stenosis with a mean aortic valve gradient 115mmHg, we performed aortic valve re-replacement (ATS AP 18mm) with an aortic root enlargement procedure. Intraoperative findings suggested that the oversizing technique was related to aortic valvular stenosis. The postoperative course has been uneventful.

Evaluation of Cerebral Oxygen Metabolism during Coronary Artery Bypass Grafting in Patients with Asymptomatic Cerebral Infarction / 日本心臓血管外科学会雑誌

We assessed the change in intraoperative cerebral oxygen metabolism during coronary artery bypass grafting (CABG) in patients with cerebrovascular desease (CVD) identified by preoperative computed tomography or magnetic resonance imaging. The study population consisted of 36 patients who underwent consecutive CABG and were divided into two groups on the basis of preoperative CVD. With near-infrared spectroscopy, the change in oxygenated hemoglobin/total hemoglobin ratio (%Oxy-Hb), which was regarded as regional tissue oxygenation, was obtained. In addition, jugular venous bulb oxygen saturation (SjO₂) was measured simultaneously. Moreover, the influence of intraoperative parameters on cerebral oxygenation was assessed by regression analysis. Thirteen patients (36%) were given a diagnosis of CVD preoperatively (group A) and were compared with the remaining 23 patients as controls (group B). All of group A were asymptomatic cerebral infarction. The average %Oxy-Hb was 51.2±4.1% in group A and 62.0±12.1% in group B (<i>p</i>=0.04), and SjO₂ was 63.5±8.6%in group A and 68.1±7.7% in group B (<i>p</i>=0.12). In serial changes, %Oxy-Hb during the late phase of cardiopulmonary bypass (CPB) and SjO₂ during the early phase of CPB were significantly lower in group A. The positive correlation between perfusion pressure and SjO₂ was demonstrated in groupA (<i>r</i>=0.699, <i>p</i><0.0001) while no correlation was observed in group B. It is concluded that patiens with silent cerebral infarctions had poorer intraoperative cerebral oxygen metabolism during CABG. It is necessary to keep a higher perfusion pressure in these patients during CPB because cerebral autoregulation may be impaired.