Waffle Procedure for a Constrictive Pericarditis as an Emerging Manifestation of Hyper-IgG4 Disease / 日本心臓血管外科学会雑誌

A 74-year-old man presenting with general fatigue and dyspnea was admitted to another hospital. He was transferred to our hospital because his symptoms deteriorated and pericardial fluid increased. The symptoms did not improve even after percutaneous pericardial drainage. On a diagnosis of heart failure due to pericardial constriction, he underwent pericardiectomy. No hemodynamics improvement was found despite subtotal pericardiectomy. Multiple longitudinal and transverse incisions like a waffle were made in the thickened epicardium and improved the hemodynamics. The symptoms improved after sugery. Steroid therapy was effective after pathological examination of the excised epicardium that confirmed an emerging manifestation of hyper-IgG4 disease. We report a waffle procedure with good results for a constrictive pericarditis with hyper-IgG4 disease.

Successful Repair in Two Cases of Traumatic Tricuspid Regurgitation / 日本心臓血管外科学会雑誌

Traumatic tricuspid regurgitation is a rare cardiovascular event that can follow blunt chest trauma. We report 2 cases of successful repair of traumatic tricuspid regurgitation. Case 1 : a 22-year-old man. At 18 years of age, he was involved in a falling accident. At the age of 19, he had an abnormal electrocardiogram and a cardiac murmur pointed out on a medical examination in his university. Echocardiography revealed severe tricuspid regurgitation, and he was referred to our institution for surgery. The operative findings showed some fenestrations in the anterior leaflet of the tricuspid valve. The fenestrations were sutured directly and ring annuloplasty was performed. Case 2 : a 54-year-old man. At age 18, he was involved in a falling accident. At age 31, he complained of fatigue and dyspnea. Echocardiography revealed severe tricuspid regurgitation. At age 54, liver dysfunction was discovered. He was referred to our institution for surgical treatment. In the operative findings, the chordae tendineae of the anterior and septal leaflets of the tricuspid valve were ruptured. Tricuspid valvuloplasty was performed using chordal replacement with 2 expanded polytetrafluoroethylene (CV-52^®) sutures, edge-to-edge sutures and ring annuloplasty.

Redo CABG Using Lateral Minimally Invasive Direct Coronary Artery Bypass Technique-Selection of Grafts, Bypass Inflow and Bypass Routes- / 日本心臓血管外科学会雑誌

We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.

Successful Surgical Treatment of Retroperitoneal Lymphocele after an Abdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

Retroperitoneal lymphocele is a very rare complication of abdominal aortic aneurysm repair. An abdominal aortic aneurysm 5cm in diameter was repaired with the retroperitoneal approach in a 70-year-old man. On the 17th postoperative day, mild abdominal distention was reported and a fever of 38°C had developed. A computed tomography scan demonstrated massive fluid collection in the retroperitoneal cavity. Total parenteral nutrition with complete fasting was initiated. A pigtail catheter was inserted into the cavity, and 1, 000ml of milky, odorless, alkaline and sterile fluid was drained. Subsequently, a retroperitoneal lymphocele following abdominal aortic surgery was diagnosed. The leaking lymph tract was ligated because the lymphocele did not improve with long term drainage. Administration of ice cream through the nasogastric tube was used to detect the leaking lymph tract, and we ligated the leaking lymph tract completely. We believe that surgical repair is an alternative strategy when conservative treatments, i. e., fasting, intravenous hyperallimentation and drainage are not effective.

A Third CABG Procedure (Axillo-Coronary Bypass) Using the MIDCAB Technique / 日本心臓血管外科学会雑誌

A 77-year-old man had undergone CABG (coronary artery bypass grafting) (SVGs (saphenous vein grafts) to LAD (left anterior descending coronary artery), OM (obtuse marginal) and RCA (right coronary artery)) 15 years previously. Three years previously, he underwent CABG again (LITA (left internal thoracic artery)-OM, RGEA (right gastroepiploic artery)-RCA) due to recurrence of angina pectoris, but there was no evidence of graft disease in the SVG to the LAD. Six months before the present procedure, graft disease developed in the SVG to the LAD and caused unstable angina pectoris. Therefore, the left axillary artery was bypass grafted to the coronary artery (LAD) using SVG without cardiopulmonary bypass by means of the MIDCAB (minimally invasive direct coronary artery bypass) technique. The patient has had no angina pectoris subsequently. Postoperative angiography revealed that the graft was patent. The axillo-coronary (LAD) bypass appears to be a useful procedure for re-revascularization to the LAD in patients with no available arterial graft, such as ITA (internal thoracic artery) or RGEA.