A Case Report of Reoperation for Björk-Shiley Mechanical Valve 38 Years after Mitral Replacement / 日本心臓血管外科学会雑誌

The patient was a 68-year-old woman who had undergone initial mitral repair at 24 years of age, and had undergone mitral replacement using the Björk-Shiley convexo-concave valve at 30 years of age. She developed exertional dyspnea 38 years after mitral replacement with hemolytic anemia. Precise examination revealed mitral stenosis and perivalvular leak. At the reoperation, severe calcified pannus was found at the ventricular side just beneath the mitral artificial valve, and made stenosis with the inadequate leaflet opening. The mitral valve remnant ring was severely calcified and the sawing ring was detached partially. Repeated valve replacement was successfully done by the reinforcement of the mitral valve ring with xenopericardium.

Ankylosing Spondylitis with Complete Atrioventricular Block and Aortic Regurgitation / 日本心臓血管外科学会雑誌

Ankylosing spondylitis is chronic, progressive, inflammatory disease involving the spine, peripheral joints, and periarticular structures. Cardiac abnormalities associated with ankylosing spondylitis are well recognized, but a case with DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for aortic regurgitation has not been previously reported. We report a case of a 66-year-old man with ankylosing spondylitis who was successfully treated by DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for severe aortic regurgitation.

Aorto-bilateral External Iliac Artery Bypass Graft in a Patient with Leriche Syndrome and an Ileal Conduit / 日本心臓血管外科学会雑誌

We report a patient with Leriche syndrome who had ileal conduit and a right lower quadrant stoma. A 47-year-old man with a history of bladder cancer had undergone radical total cystectomy with formation of an ileal conduit and right lower quadrant stoma 2 years previously. CT scanning revealed total occlusion of the distal aorta. He experienced right lower leg pain after 30 m of walking. Through a repeat midline laparotomy incision, the abdominal aorta was dissected with a transperitoneal approach. To avoid dissection around the ileal conduit, the retroperitoneum was incised (open) at the right of the ascending colon and at the left of the sigmoid colon. A prosthetic graft (Interguard 14×7 mm) was pulled bilaterally through these incisions, to the external iliac arteries. Abdominal aorto-bilateral external iliac artery bypass grafting was performed and the patient was discharged without complications on the 15th postoperative day.

Morphological Type and Histological Features of the Dilated Ascending Aorta in Patients with a Bicuspid Aortic Valve / 日本心臓血管外科学会雑誌

Bicuspid aortic valve (BAV) is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement (including coronary artery bypass grafting) from 2004 onwards, 60 (21.5%) with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta (≥45 mm) was the most common in the L/R type of BAV (48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.

Short and Long-Term Outcomes of Diabetes Mellitus in Patients with Autoimmune Pancreatitis after Steroid Therapy

BACKGROUND/AIMS: Autoimmune pancreatitis (AIP) is frequently associated with diabetes mellitus (DM). This study evaluated the effect of steroid therapy on the course of DM in AIP. METHODS: Glucose tolerance was examined in 69 patients with AIP. DM onset was classified as either a simultaneous onset with AIP or an exacerbation of pre-existing DM. Based on the changes in the HbA1c levels and insulin dose, the responses of DM to steroids were classified as improved, no change, or worsened. RESULTS: Thirty (46%) patients were diagnosed as having DM (simultaneous onset, n=17; pre-existing, n=13). Three months after starting the steroid treatment, the DM improved in 13 (54%) of 24 DM patients. The DM improved in 55%, had no change in 36%, and worsened in 9% of the 11 simultaneous onset DM patients, and it improved in 54%, had no change in 31%, and worsened in 15% of the 13 pre-existing DM patients. At approximately 3 years after starting the steroid treatment, the DM improved in 10 (63%) of 16 patients. The pancreatic exocrine function improved in parallel with the changes in the DM in seven patients. CONCLUSIONS: Because approximately 60% of DM associated with AIP is responsive to steroids in the short- and long-terms, marked DM associated with AIP appears to be an indication for steroid therapy.

Early Application of Continuous Hemodiafiltration (CHDF) after Open Heart Surgery on Hemodialysis Patients / 日本心臓血管外科学会雑誌

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, <i>n</i>=36) or hemodialysis (HD) (HD group, <i>n</i>=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, <i>p </i><0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, <i>p </i><0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

Postoperative Bleeding from the Right Lung after Aortic Root Replacement Treated Successfully with ECMO in a Patient Who Underwent Radical Operation for Tetralogy of Fallot 38 Years Ago / 日本心臓血管外科学会雑誌

We successfully performed aortic root replacement in an asymptomatic 52 year-old man with dilatation of the Valsalva sinuses (75 mm). The patient had previously undergone a radical operation for the tetralogy of Fallot at 13 years of age and AVR at 46 years of age. Massive bleeding occurred in the lungs after weaning from CPB. Emergency bronchoscopy revealed that the bleeding came from the right middle and lower lobes. The bleeding was stopped conservatively on POD 3 ; however, V-V ECMO was started on POD 5 because of severe hypoxia. ECMO was successfully weaned on POD 11 and he discharged on POD 59. The presence of developed bronchial collaterals and barotrauma during the operation were speculated the causes of the bleeding from the right lung.

Coronary Artery Bypass Grafting in Patients Aged 80 Years or Older / 日本心臓血管外科学会雑誌

Coronary artery bypass grafting (CABG) in elderly patients has been increasing in recent years. Between June 1981, and February 2004, 32 patients aged 80 years or older (mean 81.8) underwent CABG in our hospital. Twenty one patients (67%) were in New York Heart Association class III or IV. Incidence of emergency surgery in the elderly (17 of 32, 53%) was significantly (<i>p</i><0.0001) higher than that in younger patients (131 of 969, 13.5%). Total hospital deaths were 19% (6 of 32, emergency procedures 5, elective 1). The hospital deaths in patients with an ejection fraction (EF) of 45% or more (5 of 12, 42%) were significantly (<i>p</i><0.05) higher than those in patients with an EF of more than 45% (1 of 20, 5%). The main features of CABG in octogenarians was the high rate of emergency surgery and high mortality. Thus CABG in octogenarians should be performed early, before the cardiac function deteriorates, in order that treatment not be denied because of age alone.

Long-Term Results of Open Heart Surgery in Hemodialysis Patients-CABG vs. Valve Replacement- / 日本心臓血管外科学会雑誌

We evaluated 30 patients who required hemodialysis (HD) before open heart surgery between January 1990 and September 2003. The patients were divided into 2 groups according to surgical procedure: 20 patients underwent coronary artery bypass grafting (CABG group: 14 men and 6 women, mean age, 63 years), and 10 patients underwent valve replacement (VR group: 6 men and 4 women, mean age, 56 years). The mean duration of HD in the CABG group was significantly shorter than that in the VR group (67 months: 121 months, <i>p</i>=0.02). The actual survival rate was calculated by Kaplan-Meier's method. No patient was lost to follow-up. There were 3 hospital deaths in the CABG group (cerebral infarction, arrhythmia, and mediastinitis), and 2 hospital deaths in the VR group (gangrenous cholecystitis and sepsis). There were also 5 late deaths in the CABG group (acute subdural hematoma, pneumonia, AMI, heart failure and gastric cancer) and 4 deaths in the VR group (uterus cancer, 2 intracerebral hemorrhages and PVE). All cardiac event deaths in the CABG group had undergone CABG only with vein grafts. The 4-year actuarial survival rates were 56% (<i>n</i>=5) in the CABG group with a mean follow-up period of 29 months (max 156 months), and 47% (<i>n</i>=3) in the VR group with a mean follow-up period of 35 months (max 131 months). There are 3 points to improve the prognosis of open heart surgery in hemodialysis patients: control of postoperative infection in both groups, prevention of cardiac events in the CABG group and careful anticoagulation therapy in the VR group.

A Case of Traumatic Popliteal Arteriovenous Fistula Resulting in a Giant Iliac Venous Aneurysm / 日本心臓血管外科学会雑誌

A 70-year-old woman presented with extending varicose veins of her left lower extremity. She had a Seventeen years previously she suffered a stab wound in her left lower extremity. She had a thrill in her left groin and a pulsatile mass in her lower abdomen on the left side. Venography showed ‘to and fro’ sign in her popliteal vein. Arteriography and computed tomography (CT) scan revealed left popliteal arteriovenous fistula and dilated femoral artery and vein, in addition to a giant iliac venous aneurysm (9cm in diameter). The shunt ratio was calculated at 3.4. We separated the fistula using ringed ePTFE grafts. After the operation, her varicose veins remarkably diminished. CT scans showed that the iliac venous aneurysm diminished to 3.6cm with no internal thrombus at three weeks after the operation. Cases of traumatic arteriovenous fistula with venous aneurysm that occurred in parts other than the fistula are rare and there are only two cases in the international literature.

Reoperations after Operation on Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

An Adult Case of Isolated Mitral Regurgitation Associated with Marfan's Syndrome / 日本心臓血管外科学会雑誌

A 32-year-old woman with Marfan's syndrome who had had a heart murmur in childhood was admitted due to congestive heart failure. Her echocardiography showed anterior and posterior leaflet prolapse of the mitral valve, and also severe mitral valve regurgitation. Her chest CT scan showed no evidence of an enlarged ascending aorta. We performed mitral valve replacement using a mechanical valve, because the long-term results of mitral valve repair for Marfan's syndrome are unknown. We reviewed the literature for other examples of this rare adult case with isolated mitral regurgitation associated with Marfan's syndrome.

Successful Surgical Treatment for Aortic Regurgitation Associated with Aortitis Syndrome Presenting Severe Occlusive Lesions of Bilateral Carotid Arteries / 日本心臓血管外科学会雑誌

A 29-year-old female with aortic regurgitation associated with aortitis syndrome and severe stenosis of bilateral carotid arteries was reported. She had no symptom of brain ischemia, although an aortogram revealed complete occlusion of the left common carotid artery and the left subclavian artery, and severe stenosis of the right common carotid artery. The intracranial major arteries were perfused totally by the right vertebral artery via collaterals. The transcranial Doppler method and perfusion cintigraphy revealed normal cerebral perfusion. Therefore, we performed conventional aortic valve replacement without reconstruction of carotid arteries. During cardiopulmonary bypass, the mean systemic blood pressure was kept higher than 60mmHg under moderate-hypothermic (tympanic temperature: 25°C) pulsatile perfusion with monitoring of the left middle cerebral artery flow velocity. The patient did not develop any cerebral complications during or after the operation.

Initial Clinical Experience and Evaluation of a Percutaneous Left Ventricular Assist System / 日本心臓血管外科学会雑誌

We developed a percutaneous left ventricular assist system (PLVAS) using a centrifugal pump. PLVAS is the transseptal left atrial-femoral artery bypass to unload the left ventricle using a centrifugal pump. This PLVAS can be implanted through the inguinal vessels under fluoroscopy and also in 2 cases additional transesophageal echocardiogram guiding was performed. This PLVAS was applied to 6 patients with profound heart failure and refractory cardiogenic shock. The implantation of PLVAS required 30-60 minutes. The PLVAS assist flow was maintained at 3.0-4.0<i>l</i>/min. One patient with acute myocardial infarction survived and has been doing well for more than 1 year. The complications directly related to this procedure were minimal. PLVAS appears to be useful for patients with severe heart failure and may be useful as a short-time support or bridge to other more aggressive forms of life support.