Pacemaker Implantation for Atrial Fibrillation with Bradycardia in Patients with Mitral Valve Disease / 日本心臓血管外科学会雑誌

Some cases of atrial fibrillation and bradycardia show improvement in slow ventricular response after valvular surgery. However, there is still no established view regarding the indications of pacemaker implantation for the bradyarrhythmia with valvular disease. In 24 cases (permanent pacing group: 15, non-pacing group: 9) of those with bradyarrhythmia who were fitted with a myocardial pacing lead at the time of valvular surgery, we examined predictions of pacemaker implantation and the role of valvular surgery for the bradyarrhythmia. The permanent pacing group showed much larger values than the non-pacing group in regard to preoperative NYHA, right and left atrial pressure, and duration of atrial fibrillation. After valvular surgery, many cases that had significantly decreased left atrial pressure after operation improved with regard to bradycardia. We should judge the indication of pacemaker implantation after valvular surgery from the evaluation of preoperative hemodynamics and early postoperative cardiac function. Because atrial fibrillation tends to accompany bradycardia due to chronic atrial load, we must make an effort to promote the rapid recovery of cardiac function by doing valvular surgery as early as possible.

Successful Treatment of Annulo-aortic Ectasia Associated with DeBakey's Type IIIb Dissecting Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 52-year-old man with annulo-aortic ectasia and DeBakey's type IIIb dissecting aortic aneurysm was successfully treated. Aortography showed moderate to severe aortic regurgitation and enlargement of the ascending aorta, and CT showed a huge type IIIb dissecting aortic aneurysm. We scheduled a two-staged operation because dissection occurred 6 months previously and ECG showed severe LVH and ST-T change. The aortic root replacement using Bentall's procedure was performed, which was followed by arch replacement with an elephant trunk prosthesis on distal aorta. The entry in the distal aortic arch was covered by an elephant trunk prosthesis and postoperative diagnostic images showed thrombo-occlusion of the false lumen in the descending aorta. This operation was safe and might be a useful method for annulo-aortic ectasia with type IIIb dissecting aortic aneurysm.

Successful Treatment of Cluster-Like Aneurysm Associated with Coarctation of the Aorta / 日本心臓血管外科学会雑誌

A 19-year-old woman with thoracic aortic aneurysm complicating coarctation of the aorta was treated successfully. Aortography and 3D-CT showed the thoracic aortic aneurysm resembling a cluster of grapes. Coarctation of the aorta was seen between the aortic aneurysm and the descending aorta, and there was a 40mmHg pressure gradient between the ascending aorta and the descending aorta. At operation, the wall of the cluster-shaped saccular aortic aneurysm was very thin. We could see the blood flow through the wall, and we thought this patient was at high risk of ruptured aneurysm. The aneurysm was excised and replaced by a Hemashield tube graft, 16mm in diameter. The left subclavian artery was also constructed using a Hemashield tube graft, 8mm in diameter. Ruptured aneurysm in a patient with aortic aneurysm complicated by coarctation of the aorta has a high risk of death, so surgical intervention should be performed as soon as possible.

A Case of Ischemic Cardiomyopathy Complicated by Porcelain Aorta Treated with Dor Operation and CABG Using an Occlusion Balloon / 日本心臓血管外科学会雑誌

In patients with so-called porcelain aorta characterized by calcification of the total aorta, manipulation of the ascending aorta can cause cerebral infarction and other conditions due to aortic dissection or rupture and calcified debris. In the present case with ischemic cardiomyopathy and porcelain aorta, an occlusion balloon catheter was inserted into the ascending aorta to avoid its clamping, followed by Dor operation and CABG under cardiac arrest with normothermic extracorporeal circulation. Techniques such as deep hypothermic circulatory arrest and surgery while the heart is beating are often currently used as auxiliary methods to avoid aortic clamp. However, the present case with insufficient left ventricular function required a left ventriculotomy, and thus the technique presented here is useful for shortening the surgical time and ensuring a reliable outcome of the operation.

A Case of Intraoperative Acute Aortic Dissection with Coronary Occlusion during Aortic Valve Replacement / 日本心臓血管外科学会雑誌

A 70-year-old man was found to have aortic regurgitation and underwent aortic valve replacement. About 10 minutes after disconnection from the cardiopulmonary bypass, cardiac arrest occurred suddenly and the bypass was immediately resumed. At this point, a Stanford type A aortic dissection was detected by transesophageal echocardiography, and the orifice of the left coronary artery was considered to be occluded by invasion of a hematoma. Although ascending aortic replacement with a prosthesis was performed under hypothermic circulatory arrest with selective cerebral perfusion, the heart did not resume vigorous beating. Therefore, saphenous vain graftings to the left anterior descending artery and the right coronary artery were performed. Finally, the patient could be weaned from the cardiopulmonary bypass. On postoperative digital subtraction angiography, neither occlusion nor stenosis in both coronary arteries was observed. We conclude that it would be considered to perform coronary artery bypass graftings in this particular condition.