A Re-Expanding Descending Thoracic Aortic Aneurysm after Stent-Grafting / 日本心臓血管外科学会雑誌

A descending thoracoaortic aneurysm excluded by stent-grafting had expanded during a period of one and a half years. There was no endoleakage but there was shortening of the stent-landing on both proximal and distal sides. Aneurysm seemed to be pressed by blood pressure through the graft in TEE. The aneurysm was replaced by an artificial graft through a left heart bypass. Because ESP diminished during the operation, VIth intercostal arteries were reconstructed immediately, and CSF drainage was performed. Following this procedure there was no paraplegia.

Combined Coronary Artery Bypass Grafting, Abdominal Aortic Repair and Aortic Valve Replacement in a Case with Porcelain Aorta / 日本心臓血管外科学会雑誌

A 73-year-old woman was admitted to undergo three simultaneous operations: aortic valve replacement (AVR), coronary artery bypass grafting (CABG) and abdominal aortic aneurysm repair. She had previously undergone percutaneous catheter intervention in the left coronary anterior descending artery. Computed tomography revealed an abdominal aortic aneurysm 5cm in diameter. Aortic valve stenosis (AS) was shown with a pressure gradient of 60mmHg, and 90% stenosis of the distal right coronary artery was also shown. CT scan and aortography revealed porcelain ascending aorta. The patient underwent simultaneous operations because of severe AS, coronary artery disease and abdominal aortic aneurysm. An aortic cannula was placed in a position higher in the ascending aorta with no calcification. Cardiopulmonary bypass was started using a two-staged venous cannula through the right atrium. At first, AVR was performed with cardioplegic solution and ice slush. Because it was difficult to inject the cardioplegic solution into the coronary artery selectively due to the calcified orifice of coronary artery, we closed it immediately by removing the calcified intima of the porcelain aorta after completion of AVR. The second cardioplegic solution was injected through the ascending aorta. Next, CABG to RCA was performed using the right gastroepiploic artery without anastomosis to the ascending aorta. Cardiac surgery was first performed, followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. The patient was extubated the next day and stayed for two days in the intensive care unit. She is very well now one year after the operation.

A Case of Large Anastomotic Pseudoaneurysms at Both Sites Following Prosthetic Graft Replacement between Aorta and Left External Iliac Artery / 日本心臓血管外科学会雑誌

A 84-year-old man was admitted with an abdominal tumor. Prosthetic graft replacement between the aorta and the left external iliac artery was performed 17 years previously. CT scan and angiography showed a large anastomotic pseudoaneurysms at the sites of proximal and distal anastomosis. A Y graft prosthesis replacement was performed. The size of the proximal anastomotic pseudoaneurysm was 7×6×5cm, and that of the distal anastomotic pseudoaneurysm was 15×10×10cm. They resulted from cutting at anastomosis. Large anastomotic pseudoaneurysms at both sites is rare.

Combined Coronary Artery Bypass Surgery and Abdominal Aortic Aneurysm Repair during Cardiopulmonary Bypass for Patients with Severe Left Ventricular Dysfunction / 日本心臓血管外科学会雑誌

Coronary artery bypass surgery and abdominal aortic aneurysm repair were performed simultaneously during cardiopulmonary bypass in two patients with severe left ventricular dysfunction. Both patients underwent coronary artery bypass surgery first, followed by abdominal aortic aneurysm repair during cardiopulmonary bypass. Combined surgery is reasonable for patients with combined coronary artery disease and abdominal aortic aneurysm. Aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction also appears safe and effective.

Accuracy of Measurement of Cardiac Output and Circulating Blood Volume Levels by Pulse Dye Densitometry, and Postoperative Management of the Open Heart Surgery / 日本心臓血管外科学会雑誌

Using the DDG-2001 pulse dye densitometer, cardiac output (CO) and circulating blood volume (BV) were determined before and after the operation, and its accuracy and the significance of postoperative management were studied. Referring to 14 cases undergoing open heart surgery, CO and BV were determined using the DDG-2001 before application of the cardiopulmonary bypass and immediately, 4h and 12h after the operation. The level of CO was compared with that determined by the thermodilution method, and the level of BV with that calculated from hemoglobin levels determined before and after the cardiopulmonary bypass application and the priming volume in the circuit. Further, body fluid balance after the operation was calculated, and its relation to BV was studied. As to the correlation coefficient and inclination of the regression line, they were 0.77 and 0.849 with CO, and 0.821 and 0.844 with BV, respectively. Upon completion of the operation BV decreased, but increased again 4h and 12h later, although the body fluid balance was negative. CO and BV determined by the pulse dye densitometry favorably correlated with those determined by other methods. Immediately after the operation BV decreased, but then increased in the course of time, although the body fluid balance was negative.

An 81-year-old Case of Left Ventricular Aneurysmectomy with Right Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

An 81-year-old patient, who had a postinfarction left ventricular aneurysm with thrombus underwent left ventricular aneurysmectomy with right coronary artery bypass grafting (CABG). Preoperative examination showed 99% stenosis of the left coronary artery (#7) and 90% stenosis of the right coronary artery (#3). The operation was performed because angina was not improved and formation of thrombus was suspected on the wall of the aneurysm. The operation was performed under cardiopulmonary bypass and by antegrade and continuous retrograde cardioplegia. The aneurysm was resected and a relatively fresh thrombus which was detected on the endocardium of the aneurysm was extracted. The left ventricle was closed by direct linear suture with felt reinforcement. Because the area of resection included part of the left anterior descending artery, only right CABG (#3) with a saphenous vein was done. Weaning from bypass was very easy and the postoperative course was uneventful.

Effects of Single Administration of Milrinone during Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

We investigated the effects of milrinone administered during cardiopulmonary bypass (CPB) for open heart surgery. Ten patients (group M) received milrinone after aortic declamping during CPB. Ten other patients served as controls with no administration (group C). Soon after the bolus infusion of milrinone, the perfusion pressure dropped significantly in the M group, however, after CPB and at the end of operation, aortic pressure showed no difference between the two groups. There were no differences in heart rate, pulmonary artery pressure and pulmonary capillary wedge pressure. After CPB, cardiac index was high and systemic vascular resistance index was low in the M group. The need for cathecholamine and time for rewarming showed also no significant differences. No adverse reaction was recognized. During CPB, a single administration of milrinone was useful for peri- and post-operative management of patients undergoing open heart surgery.

Surgical Management for Arteriosclerosis Obliterans Complicated with Ischemic Heart Disease / 日本心臓血管外科学会雑誌

We studied the incidence of associated ischemic heart disease (IHD) among 110 consecutive patients (males 99, females 11, mean age 66.0±8.8 years) operated upon for arteriosclerosis obliterans (ASO). The screening of IHD was routinely conducted by using dipyridamole thallium scintigraphy, and when results were positive, the lesion was further confirmed by selective coronary angiography. More than 50% luminal stenosis of the major coronary arteries was judged as positive for IHD. Forty-eight patients (44%) of ASO were simultaneously afflicted with IHD. Ten patients were operated on for ASO after coronary artery bypass grafting (CABG), five for ASO and IHD (CABG) simultaneously, eight for ASO after PTCA. Twenty-five patients underwent surgery for ASO only with infusion of nitroglycerin, with or without diltiazem. We also compared 15 patients with thrombotic obliteration at the end of the abdominal aorta o: Leriche's syndrome with the remaining 95 patients in this series. The patients with Leriche's syndrome were younger and had higher incidences of hyperlipidemia (<i>p</i>=0.0254) and IHD (<i>p</i>=0.0225) than those without Leriche's syndrome. In surgical treatment for ASO, particularly for Leriche's syndrome, meticulous attention to complications is needed due to the frequent association of IHD. When both ASO and IHD are severe enough to warrant surgical treatment at the earliest opportunity, we recommend concomitant operations for ASO and IHD (CABG).

Multivessel Coronary Artery Bypass Surgery with Internal Thoracic Artery Grafts: Early and Late Besults / 日本心臓血管外科学会雑誌

Multivessel coronary artery bypass grafting (CABG) utilizing ITA grafts was performed in 110 consecutive patients, ranging in age from 24 to 76 years with a mean of 54±9 years. A mean of 3.2±0.8 grafts per patient was placed with a hospital mortality of 0.9%. Bilateral ITAs (BITA) were used in 87 patients and sequential ITA grafting (SQ-ITA) was carried out in 31, and both BITA and SQ-ITA were used in 8 patients. Noncardiac late death occurred in 1 patient and a 5-year survival rate was 98%. During this follow-up term, 11 (10%) patients underwent low-risk PTCA for ITA anastomotic stenosis (4 lesions), SVG stenosis (5 lesions) and native coronary stenosis (4 lesions) with a success in all. No reoperation has been required so far in this series. Graft patency rates were 97% for BITA with no differences for the left and right ITAs, and 100% for SQ-ITA (both proximal and distal). No sternal infection was encountered in this series, on which we believe mediastinal, sternal and subcutaneous irrigation appeared most effective. In BITA grafting, right ITA was frequently anastomosed to the LAD, passing on the aorta, which will make reoperation through a median sternotomy dangerous to this graft. To improve safety for reoperation, we have covered the ITA graft with an 8mm EPTFE graft or membrane with no side effects on ITA grafts. However, true efficacy of this protective method remains unproved because no reoperations have been required in this series of patients.