Successful Surgical Intervention for Infected Mitral Endocarditis in a Patient Complicated with Multiple Cerebral Infarction and Hemorrhage / 日本心臓血管外科学会雑誌

The optimal timing of cardiac surgery for infective endocarditis in patients with severe brain complication remains unclear. We present here the successful surgical treatment of a case of infected mitral endocarditis with intractable heart failure, disseminated intravascular coagulation (DIC), and cerebral infarction with hemorrhage. A 37 year-old woman who received chemotherapy for breast cancer developed mitral infective endocarditis perhaps caused by infection of the implanted central venous access device and was referred to our hospital for an emergency operation. On admission, she had a mild fever and showed motor aphasia and right-sided hemiplegia. Brain CT scan findings revealed a cerebral infarction in the area of the left middle cerebral artery and a cerebral hemorrhage in the right occipital lobe. Echocardiography showed severe mitral regurgitation with huge mobile vegetation. Chest X-ray revealed severe pulmonary congestion and laboratory data showed DIC. After the mitral valve replacement with a bioprosthetic valve following complete excision of infected tissue, she was extubated on the first postoperative day with dramatic improvement of infectious signs and heart failure. Postoperative brain CT showed a new small brain hemorrhage, but no aggravation of the preoperative cerebral lesion. After she underwent surgical drainage for brain abscess on the 15th postoperative day, her postoperative course was uneventful. Even though this report is limited to a single case, only aggressive and prompt surgical intervention could relieve the intractable conditions in such a patient with extremely high risk.

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.

A Case of Coronary Artery Bypass Grafting through the Left Thoracotomy after Substernal Gastric Interposition for Carcinoma of the Esophagus / 日本心臓血管外科学会雑誌

We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

Is Minimally Invasive Cardiac Surgery for Congenital Heart Defects Reasonable as a Standard Operation? / 日本心臓血管外科学会雑誌

Minimally invasive cardiac surgery (MICS) has been developed to offer patients the benefits of open heart operations with limited skin incision, but this procedure tends to be more difficult than conventional methods. We tried to evaluate whether MICS would be reasonable as a standard operation for congenital heart defects. From August 1997 to March 2000, 42 patients with atrial septal defects (ASD) and 47 patients with ventricular septal defects (VSD) underwent total repair by the minimal skin incision and lower partial median sternotomy. Fifteen ASD patients and 6 VSD patients were enrolled by residents (resident group). Twenty-seven ASD patients and 41 VSD patients were treated by leading surgeons (staff group). We compared the clinical course of the patients between resident and staff groups. Operative time, bypass time and cardiac arrest time (VSD) of the staff group were clearly shorter than those of the resident group (<i>p</i><0.05). Other clinical course parameters of the two groups showed no significant difference. The results of this study indicate that MICS for ASD and VSD is reasonable as a standard operation because there was no significant difference of postoperative clinical course except the time required for the operation.

Valvuloplasty for Aortic Valve Regurgitation Due to Congenital Bicuspid Valve / 日本心臓血管外科学会雑誌

We encountered a case of aortic valvuloplasty for aortic regurgitation due to congenital bicuspid valve. A 31-year-old man was found to have aortic regurgitation due to prolapse of a leaflet of the bicuspid valve by echocardiography. Under cardiopulmonary bypass, the right and left coronary cusps were conjoined and that conjoined cusp was larger than that of the opposing leaflet and had a longer free edge. A raphe was present in the conjoined leaflet. At first, we shortened the elongated free edge of the prolapsing leaflet by means of a triangular resection, and placed horizontal mattress sutures at each commissure. Furthermore, we performed subcommissular annuloplasty at each commissure, resulting in good coaptation of cusps. The patient survived and has shown an uneventful recovery. It is likely that this method of aortic valvuloplasty can be used for aortic regurgitation due to congenital bicuspid valve.