A Case of Stanford Type A Acute Aortic Dissection with an Innominate Artery Rupture / 日本心臓血管外科学会雑誌

We recorded a case of a 58-year-old man who presented with swelling of the right neck after sudden chest pain. He was diagnosed with Stanford type A aortic dissection. Computed tomography revealed an aneurysm in the innominate artery surrounded by a hematoma. We therefore suspected a rupture of the innominate artery. In addition, the right common carotid artery was almost completely obstructed due to dissection. An emergency partial arch replacement was performed. Cardiopulmonary bypass (CPB) was established with two blood supplies : the right axillary and left common femoral arteries. When CPB was started, the innominate artery ruptured and could no longer be used for cerebral perfusion or as an anastomotic site. The right side of the neck was opened, and a synthetic graft was anastomosed to the right common carotid artery for cerebral perfusion. Finally, the graft was anastomosed with a branch of the main trunk. The right subclavian artery was also reconstructed using a graft that was anastomosed to the axillary artery for blood supply. The postoperative course was favorable, and no cerebral complications were observed.

A Case of Purulent Pericarditis Caused by Baceteroides fragilis Successfully Treated with Pericardiotomy Using Left Small Thoracotomy / 日本心臓血管外科学会雑誌

A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

Two Cases of Bioprosthetic Valve Stenosis of the Aortic Valve Position Found on Weaning of a Nipro Left Ventricular Assist Device / 日本心臓血管外科学会雑誌

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.

A Case of Adrenocorticotropic Hormone Deficiency after Surgery for Cardiac Valvular Disease / 日本心臓血管外科学会雑誌

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.

A Case Report of Emergency Redo Operation for Active Prosthetic Valve Endocarditis after Bentall's Operation / 日本心臓血管外科学会雑誌

A 39-year-old man received Bentall's operation for annuloaortic ectasia in July 1985. He was admitted with a high fever in July 1998. On the 2nd day of his admission, he suddenly suffered from headache and dizziness. Head computed tomography showed multiple low density areas in the right cerebrum and cerebellum. A transesophageal echocardiogram revealed massive vegetation around the prosthetic valve. The patient underwent emergency operation using cardiopulmonary bypass. The left ventricle outflow was almost occluded by thrombi. The prosthetic valve and graft were removed completely and replaced with a 24mm Gelseal^® graft and a 23mm St. Jude Medical^® valve. The right coronary ostium was reimplanted directly on the prosthesis, and the left coronary ostium was reinserted using a 10mm graft. The patient's intraoperative tissues grew <i>S. aureus</i> and parenteral antibiotics were administered for 5 weeks after surgery. The patient was discharged on the 45th postoperative day and is doing well 9 months after the operation.

A Case of Occlusion of the Abdominal Aorta at the Chronic Phase of Thrombosed Type A Aortic Dissection / 日本心臓血管外科学会雑誌

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.

A Case of Extended Intramural Hematoma of the Ascending Aorta Due to Penetrating Atherosclerotic Ulcer / 日本心臓血管外科学会雑誌

An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.

Operation for Type A Aortic Dissection with a Sutureless Ringed Intraluminal Graft / 日本心臓血管外科学会雑誌

Between 1984 and 1994, 58 patients underwent operations for type A aortic dissection. A sutureless ringed intraluminal graft was used in 9 of the 58 cases. The patients ranged from 47 to 74 years old (mean, 60.4 years). Six patients were discharged from the hospital and three patients died. The operative mortality rate for the 9 patients was 33.3% and for the other 49 patients it was 20.4%. Post-operative aortograms revealed a remaining false lumen in 5 of the 6 discharged patients. The result of the operation with the sutureless ringed intraluminal graft was not satisfactory. Therefore, we prefer to resect and replace the dissected aorta using the prosthetic graft rather than repair with the sutureless ringed intraluminal graft.

A Case of Mitral Stenosis Associated with Pulmonary Arteriovenous Fistula / 日本心臓血管外科学会雑誌

We present a rare case of mitral stenosis with bilateral pulmonary arteriovenous fistulae (PAVF). A 55-year-old female who complained of dyspnea did not have pulmonary hypertension. She underwent successfully mitral valve replacement with an artificial valve 2 months after transcatheter coil embolization for PAVF. The combination with mitral valve replacement and transcatheter embolization is regarded as a useful procedure for mitral valve disease associated with PAVF.