Surgical Treatment for Aseptic Mediastinitis in the Late Phase after Aortic Root and Arch Replacement / 日本心臓血管外科学会雑誌

Objective: A few cases of an aseptic abscess after thoracic aortic surgery have been reported. However, it sometimes requires surgical treatment because the rapid growth of perigraft fluid collection results in exposure towards the body surface. We discuss the results of our treatment of these cases. Methods: This study was a retrospective analysis. Four of 341 cases who underwent thoracic aortic surgery between April 2013 and March 2020 were included. These cases presented with a bulge of the body surface 10.3 (range, 3-27) months after surgery. Results: Although the fluids looked purulent in all cases, no bacteria were detected. We diagnosed them as aseptic abscess, for which omental implantation was performed. No signs of recurrence have been found in any cases even after 5.4 (range, 1-8.5) years. Conclusions: Omental implantation was effective for controlling aseptic abscess for long-term periods.

Traumatic Aortic Dissection (Stanford Type A, DeBakey Type II) Caused by Blunt Chest Trauma / 日本心臓血管外科学会雑誌

We report the case of a 55-year-old man who received a hard blow to his chest from a liquid nitrogen hose that caused traumatic aortic dissection (Stanford type A, DeBakey type II). He did not have any other hemorrhagic injury ; therefore, we decided to perform an emergency surgery. The postoperative course was uneventful, and he was discharged on postoperative day 19. Pathological findings were compatible with traumatic aortic dissection. Blunt thoracic aortic injury is a potentially life-threatening injury ; therefore, it is worth remembering that relatively low-energy blunt trauma can cause aortic injury in patients with severe atherosclerosis. The optimal timing of intervention should be individualized in traumatic aortic injury with consideration of associated injuries.

Post-Irradiation Malignant Pericardial Mesothelioma with Recurrent Bloody Pericardial Effusion : a Case Report / 日本心臓血管外科学会雑誌

We report a case of a 64-year-old woman with a history of radiation therapy for breast cancer 27 years ago who developed malignant pericardial mesothelioma. Since 3 years ago, the recurrent bloody pericardial effusion was getting worse, which caused general edema and nocturnal dyspnea. She had a thickened pericardium and the right ventricular pressure curve showed a dip-and-plateau pattern. We diagnosed constrictive pericarditis and performed a pericardiectomy and waffle procedure on the thickened epicardium without cardiopulmonary bypass. The post-operative histology confirmed malignant pericardial mesothelioma and she died on the 17th postoperative day. Pericardial malignant mesothelioma is a rare disorder but very aggressive. This fatal disease may be considered in a patient with recurrent bloody pericardial effusion who has a history of thoracic radiation therapy.

A Surgical Case of Infective Endocarditis with Annular Abscess into Mitral Annulus Calcification / 日本心臓血管外科学会雑誌

<p>A 79-year-old man, who had undergone aortic valve replacement due to severe aortic stenosis 2.5 years previously and permanent pacemaker implantation for sick sinus syndrome 2 months after aortic valve replacement, was admitted for congestive heart failure and suspicion of prosthetic valve endocarditis. However, he had a fever in spite of medical therapy, and transthoracic echocardiography revealed a 20 mm vegetation on the posterior mitral valve leaflet. He underwent emergency surgery on a diagnosis of infective endocarditis. The intraoperative examination showed annular abscess on the calcified mitral annulus, and a part of abscess had disintegrated, from which the vegetation arose. We performed maximal possible debridement of the infected tissue and mitral annulus reconstruction with a bovine pericardium. Subsequently, mitral valve replacement and annulus reinforcement with a prosthetic valve collared with a bovine pericardium were performed to prevent perivalvular leakage. The patient showed no recurrence of infection and perivalvular leakage at 1.5 years of follow-up.</p>

Surgical Treatment for Prosthetic Infective Endocarditis Complicated by Superior Mesenteric Artery Embolism / 日本心臓血管外科学会雑誌

<p>A 75-year-old man, who had undergone aortic valve and ascending aorta replacement at the age of 73 years, was admitted to our hospital with one week of fever. Blood culture showed growth of <i>Streptococcus bovis </i>and echocardiography showed vegetation on the prosthetic valve. Although antibiotic treatment was commenced, he complained of abdominal pain, and computed tomography showed a superior mesenteric artery embolism. The abdominal pain improved with fasting, but echocardiography showed another vegetation, and re-aortic valve replacement was performed to prevent embolism recurrence. When he resumed eating postoperatively, he again complained of abdominal pain and computed tomography showed mesenteric ischemia. The necrotic intestine was extensively resected and he recovered successfully. A superior mesenteric artery should be revascularized to 2/11 prevent perioperative mesenteric ischemia when cardiac surgery complicated by acute superior mesenteric artery embolism is performed.</p>

A Case of Aorto-Right Atrial Fistula Following Acute Type A Dissection Repair / 日本心臓血管外科学会雑誌

Patients with an aortic root pseudoaneurysm communicating to the right atrium are rare. A 67-year-old woman underwent ascending aorta and total aortic arch replacement for acute type A aortic dissection at our institute 9 years prior to the current presentation. She was transported to our emergency department with complaints of chest pain, palpitations, and cold sensation. A continuous murmur was heard at the right sternal margin. Contrast-enhanced computed tomography (CT) and ultrasonic cardiography showed a huge pseudoaneurysm at the proximal anastomotic site and an aorto-right atrial fistula. Ascending aortic replacement with concomitant direct closure of the fistula was successfully performed. The patient was discharged in good condition on the 14th postoperative day. Careful follow-up with CT is important after acute type A aortic dissection repair.

Cardiac Surgery for a Patient with CD36 deficiency and Aortic Valve Regurgitation / 日本心臓血管外科学会雑誌

We describe a case of cardiac surgery for a patient with CD36 deficiency. A 56-year old man had progressive dyspnea on effort for 1 year. On admission, echocardiography revealed severe aortic valve regurgitation. He required medical treatment for heart failure, and subsequently elective aortic valve replacement was planned. Pre-operative cardiac scintigraphy (¹²³I-BMIPP) showed total defect of myocardial uptake. CD 36 deficiency was diagnosed based on the characteristic findings. CD 36 deficiency could cause transfusion related complication by donor blood transfusion. We prepared 1,200 ml autologous blood preoperatively in a two week period. The operation was performed successfully without donor blood transfusion. He was discharged uneventfully.

Cardiac Surgery in Homozygous Familial Hypercholesterolemia / 日本心臓血管外科学会雑誌

Homozygous familial hypercholesterolemia is a rare metabolic disorder with characteristic clinical presentations, such as tendon xanthomas, hypercholesterolemia, and significant cardiovascular disease including premature coronary artery disease. We describe a case of a 56-year-old woman with homozygous familial hypercholesterolemia. She had been treated with low-density lipoprotein apheresis for 23 years. Preoperative echocardiography and coronary angiography showed severe aortic valve stenosis and right coronary artery stenosis. Aortic valve replacement with patch enlargement of the aortic valve annulus, and coronary artery bypass grafting were successfully performed. She was discharged uneventfully.

A Case of Successful Surgical Treatment for Acute Type A Aortic Dissection in Late Pregnancy with Marfan Syndrome / 日本心臓血管外科学会雑誌

We report a case of successful surgical treatment for acute aortic dissection in a patient with late pregnancy with Marfan syndrome. The patient was a 32-year-old primipara. She experienced sudden precordial pain and visited on other hospital at 29 weeks' gestation. She was given a diagnosis of acute type A aortic dissection on computed tomography (CT), and was referred to our hospital for surgery. The earliest possible operation was required, but, in view of the risk of massive bleeding following placental separation due to heparin administration for cardiopulmonary bypass, Caesarian section and abdominal total hysterectomy were initially performed, followed 2 days later by the Bentall procedure plus prosthetic graft replacement of the ascending aorta and aortic arch in a two-stage operation. The postoperative course of the mother and infant was uneventful. The treatment strategy for Marfan syndrome complicated by aortic dissection in late pregnancy is very important. We were able to safely perform surgery and perioperative management using a two-stage operation, that is, by performing Caesarian section first, then strictly controlling circulatory dynamics under sedation and artificial ventilation in the ICU, and subsequently performing repair of the heart and aorta after the subsidence of obstetric hemorrhage.

Acute Type A Aortic Dissection with Acute Left Main Coronary Trunk Occlusion : A Case Report of Left Main Stenting as a Bridge to Surgery / 日本心臓血管外科学会雑誌

A 56-year-old man was admitted to our institution with sudden onset of severe chest pain and ischemia of the lower extremities on February 24, 2007. An enhanced computed tomography scan showed acute Stanford type A aortic dissection. Electrocardiography showed ST segment elevation in leads V_1-4 and a transthoracic echocardiogram revealed antero-septal wall akinesis. The patient was given a diagnosis of acute myocardial infarction (AMI) caused by left main trunk dissection (LMT) due to acute aortic dissection. Coronary angiography (CAG) showed severe stenosis in the LMT with poor distal run-off. For this reason, after we implanted a stent in the left main coronary trunk to maintain coronary blood flow, we performed total aortic arch replacement, coronary artery bypass grafting (SVG-LAD #8), and F-F cross-over bypass. Removal of the implanted stent from the LMT during the operation was simple. Postoperative CAG showed a patent SVG and intact LMT. Because preoperative PCI is still controversial for acute aortic dissection with AMI, either more immediate surgery or preoperative PCI (bridge stent to surgery) in the left main coronary artery is mandatory. Implantation of an LMT stent, as a bridge to surgery, is an effective strategy for acute type A aortic dissection with LMT occlusion before surgical repair.

A Case of Surgical Treatment for Pseudoaneurysm 19 Years after Aortic Root Replacement / 日本心臓血管外科学会雑誌

We report a case of surgical treatment for pseudoaneurysm 19 years after aortic root replacement. The patient was a 57-year-old female who had undergone aortic root replacement (Piehler procedure) in another hospital due to acute Stanford A type aortic dissection in 1988, and was then followed up at another hospital. However, a low density area around the artificial graft was pointed out on computed tomography (CT) in 2001, which increased to 60mm in size by November, 2006. She was then referred to our hospital for a redo operation. Pseudoaneurysm of the anastomosis and mitral regurgitation (MR) was diagnosed by the examination of the CT, angiography, etc., and we performed ascending aorta and aortic arch replacement, and mitral valve replacement (MVR) in April, 2007. A slight hemorrhage were found at the anastomosis of the artificial graft-artificial graft. Deterioration of the artificial graft or deterioration of the suture was suspected as the cause of the slight hemorrhage from the anastomosis a long period after the operation. In this case, loosening of the suture string was revealed, so the latter was more strongly suspected.

A Case of Heparin-Induced Thrombocytopenia (HIT) following Aortic Surgery for Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

A 44-year-old man underwent total arch replacement for acute type A aortic dissection. He was treated postoperatively in the intensive care unit for acute renal failure and respiratory failure. Although recovery of organ functions was seen, an unexpected fall in platelet count (PLT) occurred abruptly on postoperative day (POD) 7. The patient was treated with gabexate mesilate and platelet transfusion because disseminated intravascular coagulation (DIC) was initially suspected. Nevertheless, PLT dropped rapidly below 1.0×10⁴/μl. We suspected heparin-induced thrombocytopenia (HIT) and stopped all heparin administration including flush solution for pressure monitoring lines. The platelet factor 4-reactive HIT antibody test was performed and we began to give intravenous argatroban, 60mg/day. However, PLT did not increase at all. Multiple organ failure developed and metabolic acidosis deteriorated rapidly resulting in death on POD 15. HIT antibody was positive on POD 13 and a definitive diagnosed of HIT was made. For those patients treated with heparin continuously or repeatedly, HIT may occur and increase the mortality risk if the diagnosis is delayed.

Mediastinitis following Graft Replacement of the Ascending and Total Arch Aorta in Two Cases / 日本心臓血管外科学会雑誌

Mediastinitis following graft replacement of the ascending and total arch aorta is a fatal complication of cardiac surgery. When graft infection is suspected, one choice of treatment is to remove the infected prosthesis and replace it with a new one. However such a procedure seems to be very risky. We report 2 successfully treated cases of mediastinitis following graft replacement of the ascending and total arch aorta. In one case, we treated with primary sternal closure after debridement and omental flap implant. In another case, the wound was left open and irrigation with iodine solution was undertaken for 6 days. The sternum was closed with pectoralis major muscle flap implantation. When graft infection is not suspected, primary sternal closure with implantation of tissue flaps is recommended. When graft infection is strongly suspected, we prefer secondary sternal closure after open irrigation.

A Case of Ruptured Thoracoabdominal Aortic Aneurysm Repair under Profound Hypothermia Using Subclavian Arterial Perfusion through Right Axillo-Bifemoral Bypass Graft Implanted Ten Years Previously / 日本心臓血管外科学会雑誌

A 74-year-old woman had undergone right axillo-bifemoral bypass for infrarenal aortic stenosis due to aortitis syndrome in another hospital. She was admitted as an emergency case to our hospital with a ruptured thoracoabdominal aortic aneurysm, and an emergency operation was performed. We used arterial cannulation to the artificial vascular graft implanted for axillo-bifemoral bypass and first cooled the body temperature to below 25°C, then dissected the aorta. In the case of ruptured descending and thoracoabdominal aortic aneurysm, profound hypothermia is a valuable adjunct for unexpected blowout rupture during the preparation of the aneurysm and spinal cord and visceral protection.

Successful Management of Infected Superficial Femoral Aneurysm Caused by Citrobacter koseri / 日本心臓血管外科学会雑誌

A 77-year-old man with diabetes mellitus and hypertension presented with acute onset of pain and swelling of the right thigh. Physical examination showed a pulsatile mass in the mid-portion of the right thigh. Computed tomography revealed the presence of a 7-cm diameter aneurysm at superficial femoral artery with gas shadow around the aneurysmal wall. A diagnosis of infected superficial femoral aneurysm was made and emergency surgery was undertaken. The total resection of the aneurysmal wall, debridement of necrotic tissues including part of sartorius and quadriceps muscles were done. Femoro-popliteal bypass through subcutaneous route using a 6-mm diameter Dacron prosthesis was used as the mean of vascular reconstruction procedure. <i>Citrobacter koseri</i> was cultured from the infected aneurysmal wall. The antibiotic treatment was continued for total of 2 weeks. Although additional debridement was required, the patient was amkulabony when discharged on the 37th postoperative day.

Successful Management for Aortic Valve Insufficiency in a Childbearing Age Patient with Type II Ehlers-Danlos Syndrome / 日本心臓血管外科学会雑誌

A 16-year-old schoolgirl had aortic valve insufficiency, detected incidentally on electrocardiogram taken for a physical checkup. She was noted to have hyperextensibility of joints, hyperelasticity of the skin and an atrophic scar over the knees on physical examination and type II Ehlers-Danlos syndrome (EDS) was diagnosed by skin biopsy after admission. A Carpentier-Edwards pericardial bioprosthesis was chosen for aortic valve replacement because she was of childbearing age and had EDS. Seven years after the replacement she became pregnant, resulting in spontaneous vaginal delivery of a healthy male infant at 39 weeks. However, a second aortic valve replacement was staged for structural failure of the bioprosthesis which was accelerated during the gestation. Aortic valve re-replacement was carried out using a 21-mm Sorin Bicarbon mechanical prosthesis 4 months after the delivery. She was discharged on the 10th postoperative day without any complications.

Reoperations after Total Arch Replacement in Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

Gelatin-resorcin-formalin (GRF) glue has been widely used in repair of dissected aortic wall tissue, and the use of GRF glue has been reported to significantly reduce mortality from this surgical emergency. On the other hand, various late complications possibly due to GRF glue have also been reported. We performed reoperations after total arch replacement for acute type A aortic dissection using GRF glue in 2 cases. In case 1, total arch replacement was performed 3 years ago. Pseudoaneurysms of the aortic root and brachiocephalic artery and redissection of the descending aorta were revealed by subsequent computed tomography (CT). Partial graft replacement for these 3 sites were performed with open distal anastomosis and right common carotid artery perfusion. In case 2, total arch replacement was performed 5 years previously. Redissection of the aortic root was revealed by CT, and ultrasound cardiography revealed severe aortic regurgitation and severe mitral valve insufficiency. A modified Bentall procedure and mitral valve replacement were performed. In these 2 cases, the sites of redissection and pseudoaneurysm were identified as the sites of use of GRF glue at the first operation. We suspected that the use of GRF glue is associated with a certain amount of risk of redissection and pseudoaneurysm. Such patients should be carefully followed for years after surgery. It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue.

A Case of Traumatic Injury to the Thoracic Descending Aorta Complicated with Intracerebral Hemorrhage / 日本心臓血管外科学会雑誌

A semicomatose 53-year-old woman who had been injured in an automobile accident was admitted. Injury to the thoracic descending aorta was suspected because of widening of the upper mediastinum on a chest X-ray film and confirmed by chest contrast-enhanced computed tomography (CT). We postponed surgical treatment because brain CT showed traumatic intracerebral hemorrhage. She was maintained in an intensive care unit and had pharmacological treatment and medical support. Two days later, brain CT showed that the intracerebral hematoma was a stable and inactive lesion, so she underwent aortic repair 3 days after the accident. Left thoracotomy was performed and an artificial vascular prosthesis was interposed under hypothermic circulatory arrest (open proximal method). The postoperative course was uneventful and the patient was discharged 44 days after the operation. Hypothermic circulatory arrest may be a valuable adjunct for traumatic injury of the thoracic aorta at risk for impending rupture.

A Case of Dacron Graft Aneurysm 18 Years after Left Subclavian Artery-Descending Aortic Bypass / 日本心臓血管外科学会雑誌

Dacron grafts have made great progress and the material has become almost perfect recently. However, we encountered a rare case of a late-graft complication. A 34-year-old man was operated on for coarctation of the aorta in July 1982. Left subclavian artery-descending aortic bypass was performed using a Cooley double velour knitted graft. Eighteen years later, the patient was admitted to our hospital with an abnormal shadow in his chest X-ray. Angiography and computed tomography demonstrated a non-anastomotic aneurysm of the graft. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, reoperation with a woven Dacron graft was successfully performed. This case suggests that it is important to follow up patients with implanted Dacron arterial prostheses because of the potential for rupture.

Successful Surgical Treatment for an Aortic Arch Aneurysm Combined with an Aberrant Right Subclavian Artery / 日本心臓血管外科学会雑誌

An 81-year-old man complaining of back pain was admitted. Computed tomographic scan revealed an aortic arch aneurysm and an abnormal retroesophageal artery. It was believed to be an aberrant right subclavian artery. The diagnosis was confirmed by angiogram. Although there was no evidence of rupture, his back pain prompted us to perform emergency surgery. Through median sternotomy using a cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion, total arch replacement was done. There was evidence of impending rupture, which was probably the cause of his back pain. The proximal portion of the aberrant right subclavian artery was severely calcified, so the right subclavian artery was reconstructed. It was anastomosed with one branch of the arch graft which passed the anterior of the trachea. The postoperative course was uneventful. We believe median sternotomy was a proper approach for such a situation.