Apicoaortic Bypass with Coronary Artery Bypass Grafting for a Case of Severe Aortic Stenosis / 日本心臓血管外科学会雑誌

We describe a 77-year-old woman with severe aortic stenosis, porcelain aorta and coronary artery disease, who underwent apicoaortic bypass with coronary artery bypass grafting. The patient, who had a history of aortitis syndrome had dyspnea. Cardiac echocardiography showed severe aortic valve stenosis (aortic valve pressure gradient (max/mean) = 115/74.4 mmHg, aortic valve area = 0.48 cm²). Coronary angiography showed severe stenosis of right coronary artery orifice (#1.90%) . Computed tomography showed severe calcification of the thoracic aorta and surgical manipulation for ascending aorta was impossible. We did not perform ordinary aortic valve replacement. Instead, apicoaortic bypass with coronary artery bypass grafting was performed. We approached by a left anterolateral thoracotomy at the 6th intercostal level. Apicoaortic valved conduit (valved graft : Edwards Prima Plus Stentless Porcine Bioprosthesis 19 mm + UBE woven graft 16 mm) was implanted. Saphenous vein graft was harvested and coronary bypass grafting (valved conduit-#4AV) was performed in the same operative field. Postoperative cine MRI showed that most of the cardiac stroke volume flowed through the conduit (44.4 ml/beat, 92.3%), with the flow via the aortic valve accounting for 3.69 ml/beat, 7.7%. Postoperative enhanced CT showed that the coronary artery bypass graft was patent. Apicoaortic bypass is a good surgical option for aortic stenosis with severe calcification aorta and coronary artery bypass grafting can also be performed in the same view.

Finger Lifting Resternotomy Technique / 日本心臓血管外科学会雑誌

We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3 cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator's finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.

Successful Valvuloplasty for Tricuspid Valve Regurgitation due to Blunt Trauma / 日本心臓血管外科学会雑誌

A 34-year-old man had been in a motor vehicle accident at age 21. Thirteen years later, he complained of fatigue and palpitations, and was evaluated at an outside hospital. Echocardiography revealed severe tricuspid regurgitation and the patient was referred to our institution for treatment. The anterior leaflet of the tricuspid valve was torn and the attached chorda was also torn. The torn anterior leaflet was sutured directly, and an artificial chorda was created using an e-PTFE suture. An annuloplasty was performed with a 34mm Carpentier-Edwards ring. The patient's recovery was uneventful, and postoperative echocardiography revealed no regurgitation.

Reoperation following Aortic Valve Replacement Using Tilting Disc Valve Prostheses / 日本心臓血管外科学会雑誌

Fifty-three patients who had received aortic valve replacement (AVR) using tilting disc valve prostheses (Lillehei-Kaster valve, Omniscience valve, Omnicarbon valve), underwent replacement of their aortic valve prostheses over the past 13 years. The indications for reoperation were non-structural opening failure in 35 patients, thrombosed valves, including 2 stuck valves in 8, prosthetic valve endocarditis (PVE) in 7 and perivalvular leakage (PVL) in 3. The interval periods until reoperation for opening failure and thrombosed valve were 112 and 118 months respectively, and for PVE and PVL were 21 and 25 months. There were 7 hospital deaths (13.2%). Surgical results in cases of active PVE with root abscess and stuck valve required emergency operation were significantly worse than these for nonstructural opening failure. Opening failures, which accounted for two-thirds of the indications for reoperation was found to be due to subvalvular pannus formation on minor orifices which hindered the disc from opening properly. It was suggested that reoperation for these types of prosthetic valve should be done before they develop into emergency cases, taking account of these valve-related complications.