A Case of Giant Mobile Left Atrial Thrombus during Dabigatran Therapy / 日本心臓血管外科学会雑誌

Dabigatran is a new/direct oral anticoagulant drug unlike warfarin. It is being increasingly used to prevent thromboembolism in patients with nonvalvular atrial fibrillation. We present the case of a 77-year-old woman with a giant left atrial thrombus in spite of anticoagulation therapy with dabigatran 300 mg/day. She had developed a cerebral infarction 18 months previously and was switched from warfarin to dabigatran. However, magnetic resonance imaging showed multiple new cerebral infarcts, and computed tomography scan and echocardiogram revealed a giant thrombus measuring 37×29 mm in the left atrium. Thrombectomy and left atrial appendage closure were urgently performed. Dabigatran was changed to warfarin again after the operation. She has had no recurrent thromboembolic event since then.

Re-expansion Pulmonary Edema after Mitral Valve Plasty via Small Right Thoracotomy / 日本心臓血管外科学会雑誌

We report a case of re-expansion pulmonary edema (REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were introduced, and they were very effective. After five-days' support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.

A Case of Giant Coronary Aneurysm of the Septal Branch / 日本心臓血管外科学会雑誌

We report a case of septal branch aneurysm. A 61-year-old woman was referred to our hospital because of heart murmur. Septal branch aneurysm (25×15 mm) was diagnosed by echocardiography and coronary angiography, and followed up annually with multi-detector row computed tomography (MDCT). Nine years later, another aneurysm proximal to the known aneurysm, which protruded above the epicardium, has rapidly dilated from 5 to 11 mm. We therefore performed closure of the orifice of the septal branch concomitant with bypass grafting ; left internal mammary artery to distal LAD. After the procedure, the aneurysm in the septum had completely collapsed. Her postoperative course was uneventful.

A Case of Takotsubo Cardiomyopathy, Which Occurred after CABG and Was Complicated with Left Ventricular Outflow Tract Stenosis and Mitral Regurgitation / 日本心臓血管外科学会雑誌

We report a case of Takotsubo cardiomyopathy that developed after elective coronary artery bypass grafting (CABG) in an 80-year-old woman. She had been given a diagnosis of unstable angina complicated with mild hypertrophic obstructive cardiomyopathy (HOCM). Her cardiac index began to fall 7 h postoperatively, and we needed to infuse fluids and increase dopamine dose (up to 5 µg/kg/min) to maintain cardiac index and blood pressure. CPK-MB level increased up to 140 IU/<i>l </i>at 12 h postoperatively. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base with accelerated left ventricular outflow tract (LVOT) flow and increased mitral regurgitation (MR). Emergency coronary artery angiography showed good patency of all bypass grafts and no new coronary lesion. We diagnosed Takotsubo cardiomyopathy. To improve the hemodynamic status, we started intra-aortic balloon pumping (IABP) instead of adding catecholamines. Blood pressure and cardiac index had improved temporarily, but became unstable again because of increased LVOT pressure gradient and moderate-to-severe MR. LV wall motion gradually improved, but the hemodynamic status stayed unstable, but improved after removal of IABP. In general, the prognosis of Takotsubo cardiomyopathy is favorable with supportive care. However, when it is associated with LVOT stenosis and significant MR, low cardiac output syndrome can become intractable, thus we should manage critical conditions with extreme caution.

Coronary Aneurysms in an Elderly Man Presumed to Be due to Childhood Kawasaki Disease / 日本心臓血管外科学会雑誌

A 60-year-old man was admitted to our institution with abnormal ECG findings. Coronary CT and angiography showed coronary aneurysms from the left main trunk to the bifurcation of the left anterior descending artery, and the left circumflex artery, with severe stenosis and complete obstruction of the proximal right coronary artery. Morphological evaluation findings strongly suggested that the coronary aneurysms were highly related to childhood Kawasaki disease. We successfully performed triple vessel coronary artery bypass grafting. Here, we report a very rare case of coronary aneurysms presumed to be due to childhood Kawasaki disease in an elderly man.

Comparison of Clinical Outcomes Using EuroSCORE for Coronary Artery Bypass Grafting with or without Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

We reviewed 223 cases of isolated coronary artery bypass grafting (CABG) during the past 6 years, and used the EuroSCORE to assess the differences in clinical outcomes between off-pump CABG (OPCAB) and on-pump CABG (conventional CABG: CCABG). After March 2000, our first choice has been OPCAB, with CCABG selected only for cases with unstable hemodynamics. The total of 223 isolated CABG cases consisted of 129 OPCAB and 94 CCABG, but after March 2000, 94 OPCAB and 42 CCABG were performed. Mean EusoSCORE was 5.8 for OPCAB and 4.1 for CCABG, and corresponding expected survival rates were 7.20% and 5.04%. The 3 cases of hospital death (mortality, 1.3%) all belonged to the earlier CCABG groups and were not related to cardiac death. After March 2000, no hospital deaths occurred in either group. Midterm results showed 5 deaths, but these were not related to cardiac death, either. There were no significant differences between the 2 groups in terms of hospital complications other than long mechanical ventilation time, which was markedly longer only for the OPCAB groups (<i>p</i><0.01). Mean number of grafts was significantly high for patients in the CCABG groups (OPCAB 2.1 vs. CCABG 2.8; <i>p</i><0.05). We have therefore been using OPCAB for high-risk cases, and midterm results of our CABG patients were satisfactory.

Long-term Results with 90 Composite Graft Replacements of the Ascending Aorta and Aortic Valve / 日本心臓血管外科学会雑誌

From May 1975 to August 1991, 90 patients (56 males and 34 females) underwent Bentall's operations or its modified technique. In our modified technique the coronary ostium is cut out like a button and anastomosed to the aortic graft and aortic grafts are not wrapped by the aortic wall. Preoperative diagnoses were AAE (25 patients, 28%), Stanford type A dissection (19, 21%), Marfan's syndrome (16, 18%), aortitis syndrome (12, 13%), AR+ascending aortic aneurysm (6, 7%), syphilitic aortitis (5, 6%), AS+ascending aortic aneurysm (3, 3%), Valsalva's sinus aneurysm (2, 2%) and other diseases (2, 2%). The hospital mortality rate was 17% (15/90) for all cases. The hospital mortality for aortic dissection (37% (7/19)) and reoperation cases (75% (3/4)) were very high. There were 10 cases of late death and the 10 year actuarial survival rate was 66.3%. Among 11 cardiovascular events which occured in the late phase, 5 were dissection at other aortic sites in the type A dissection and Marfan syndrome cases, and 3 were pseudoaneurysm formation at the site of coronary or the aortic anastomosis in the aortitis syndrome cases, and a detachment of the composite graft in the Marfan's syndrome cases. The 10-year event-free rate was 92.0% for non-specific AAE, 68.8% for aortitis syndrome, 61.9% for Marfan's syndrome and 47.3% for Stanford type A dissection. Non-specific AAE had excellent long-term results, but Marfan's syndrome and dissection had poor results. The button technique for coronary reconstruction is effective for all cases and its long term results are good, but, even with this technique, coronary pseudo-aneurysm occured in cases of aortitis syndrome.

Retroperitoneal Approach to Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

To evaluate the efficacy of the retroperitoneal approach (RP) when compared with the transperitoneal approach (TP) in elective aortoiliac reconstruction, 41 cases were reviewed. From February 1987 through October 1991, 16 patients underwent aortoiliac reconstruction through the TP approach and 25 patients underwent operation through the RP approach for abdominal aortic aneurysms (AAA). The TP approach was associated with larger intraoperative blood loss (648.6±416.5ml) when compared with the RP approach (357.7±208.9ml) (<i>p</i><0.01). The TP approach was associated with greater intraoperative blood transfusion (2093.8±1179.0ml) when compared with the RP approach (1010.4±905.3ml) (<i>p</i><0.01). Both groups had similar operative times. Postoperative initiation of oral water intake was prolonged in the TP group (50.2±27.4hr) when compared with the RP group (22.3±8.9hr) (<i>p</i><0.01). Postoperative initiation of walking training was prolonged in the TP group (88.7±37.1hr) when compared with the RP group (60.1±23.2) (<i>p</i><0.01). This experience demonstrates that the RP approach is a preferable alternative to the TP approach in elective aortoiliac reconstruction.