A Case of Stanford Type A Acute Aortic Dissection with Occlusion of Prosthesis Implanted in the Abdominal Aorta / 日本心臓血管外科学会雑誌

A 54-year-old woman underwent abdominal aortic replacement for abdominal aortic aneurysm in March 2012. Approximately 6 months after surgery, she was taken by ambulance to hospital due to thoracodorsal pain, lower limb paralysis and pain. Emergency computed tomography indicated acute aortic dissection involving the ascending aorta, aortic arch, and descending aorta. The outline of the prosthesis implanted in the abdominal aorta was absent, and emergency surgery was performed immediately by median sternotomy to treat suspected complete obstruction. Following confirmation of brachiocephalic artery dissection, extracorporeal circulation was started with drainage of blood from the vena cava and the return via left axillary artery, plus perfusion in both lower limbs. However, the level of regional oxygen saturation declined as the flow of extracorporeal circulation increased. To solve this problem, an incision was made in the ascending aorta, and an aortic cannula was inserted directly into the true lumen. Aortic arch replacement was then performed, but this central repair failed to improve blood flow in both the left and right femoral artery. Proximal thrombectomy successfully removed a large amount of thrombi, but did not improve blood circulation. Left axillobifemoral bypass was subsequently performed, and improved lower limb blood circulation, but with residual motor impairment. Since the patient regained somatosensory sensation and was able to perform simple exercises, rehabilitation was started. Hemodialysis was required after abnormal increases in muscle enzyme levels and white blood cell count, but this was later discontinued following improvement of renal function. The patient was transferred to a rehabilitation clinic 54 days after surgery.

Two Cases of Postinfarction Ventricular Septal Perforation due to Obstruction of the Right Coronary Artery / 日本心臓血管外科学会雑誌

We report 2 cases of postinfarction ventricular septal perforation (VSP) attributable to obstruction of the right coronary artery. Case 1 was a 63-year-old man in whom VSP developed after percutaneous coronary angioplasty for complete obstruction of the right coronary artery. He developed papillary muscle rupture intraoperatively, requiring mitral valve replacement and subsequent treatment for right-side heart failure. He was discharged l7 weeks after surgery. Case 2 was a 77-year-old man. During catheterization following the detection of 99% obstruction of the #2 segment of the right coronary artery, VSP was found and the patient underwent emergency surgery. Postoperative echocardiography and ventriculography did not reveal a residual shunt or mitral regurgitation (MR). However, he suddenly developed acute MR in the 4th postoperative week and died of acute heart failure. VSP attributable to obstruction of the right coronary artery is difficult to repair surgically because of its anatomical location, among other reasons, and mitral valve replacement is sometimes needed if VSP is accompanied by necrosis of the mitral valve papillary muscle. Appropriate care is therefore needed in this case.

An Implantable Cardioverter-Defibrillator Rescued a Patient from Potentially Lethal Arrhythmias after Partial Left Ventriculectomy / 日本心臓血管外科学会雑誌

A 36-year-old man underwent partial left ventriculectomy (PLV) to treat end-stage dilated hypertrophic cardiomyopathy. Mitral valve replacement and tricuspid valve annuloplasty were performed to correct the mitral and tricuspid valve insufficiency. The patient suffered ventricular tachycardia and ventricular fibrillation (VT/VF) soon after surgery, but antiarrhythmic-drug therapy was sufficiently effective to treat the VT/VF. On the third postoperative day, an implantable cardioverter-defibrillator (ICD) was implanted to prevent these arrhythmias. Two months later after his discharge from the hospital, recurrent VT/VF appeared and was supposedly associated with renal failure. Continuous hemodialysis was efficacious to ameliorate the systemic circulation, and ventricular arrhythmias disappeared. He survived due to 18 ICD shocks. In appropriately selected patients, ICDs have been recognized as one of the cost-effective therapeutic options. ICDs might be recommended for patients in the postoperative period of PLV who have potentially lethal ventricular arrhythmias resistant to antiarrhythmic-drug therapy.

Pitfalls in Open Stent Grafting for Distal Aortic Arch Aneurysm / 日本心臓血管外科学会雑誌

A 72-year-old woman underwent surgical stent graft implantation for a huge distal arch aneurysm (12×11cm). Axillo-bifemoral bypass was added in order to restore visceral perfusion. Severe metabolic acidosis developed after the operation, and the patient died 6 hours after surgery. Autopsy showed thromboembolism of the superior mesenteric artery and aortic dissection in the descending thoracic aorta because of stent graft insertion into a false lumen. To reduce complications like this case, we should consider the peculiar anatomic features and thoroughly evaluate atheromatous changes in the aortic wall with improvement of the shape of the sheath and delivery system.

Partial Left Ventriculectomy (Batista procedure) and Its Perioperative Management / 日本心臓血管外科学会雑誌

This report describes the surgical technique for partial left ventriculectomy (PLV) and perioperative management. We have performed PLV to treat end-stage non-ischemic cardiomyopathy in 6 patients (4 men and 2 women, mean age: 59 years) since February 1998. Preoperative New York Heart Association (NYHA) functional class was III or more in all patients. On echocardiography, the mean left ventricular diastolic dimension was 75mm, and the mean ejection fraction was 29%. One patient was operated on with cardiogenic shock, and 5 were elective cases. A wedge of the left ventricular muscle was removed from the apex to the base of the two papillary muscles. Associated surgical procedures were as follows; mitral valve reconstruction in 5 patients (4 replacements and 1 annuloplasty), tricuspid annuloplasty in three, and aortic valve replacement in one. Five elective patients were successfully weaned from cardiopulmonary bypass, but one emergency surgery case required intraaortic balloon pumping. Two patients died in the hospital: one elective case was due to multiple organ failure, and one emergency case due to low output syndrome. Three of 4 survivors returned to NYHA functional class I-II, and 1 remained in class III. We are very cautious to ensure that extended PLV does not to lead to serious diastolic dysfunction. The complete reconstruction of the mitral valve and the preservation of annular-chordal-papillary muscle continuity result in the maintenance of left ventricular function and geometry. The practical principles in the post-PLV period are to maintain adequate preload and to avoid excessive afterload. Further studies are required to further enhance outcome.