Surgical Treatment for a Patient with Crawford Type III Thoracoabdominal Aortic Aneurysm Associated with Occlusion of the Visceral and the Iliac Arteries / 日本心臓血管外科学会雑誌

We report a case with Crawford type III thoracoabdominal aortic aneurysm associated with occlusion/stenosis of the visceral and the iliac arteries necessitating surgical repair. The patient was a 54-year-old man. His visceral arteries were obstructed except the left renal artery which was stenotic. His iliac arterial system was also completely occluded except the patent left common and internal iliac arteries. The blood flow of his visceral organs and lower extremities depended on the collateral vessels from the left internal iliac artery. We successfully performed thoracoabdominal aortic aneurysm repair concomitant with reconstruction of the visceral arteries and the femoral arteries using partial cardiopulmonary bypass between the left internal iliac artery and the left femoral vein. It is important to select appropriate adjuncts and surgical options for patients with thoracoabdominal aortic aneurysms that involve visceral/iliac arteries.

Surgical Treatment of Active Infective Endocarditis: Determinants of Early Outcome / 日本心臓血管外科学会雑誌

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). <i>Streptococci</i> (27.5%) and <i>Staphylococci</i> (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (<i>p</i>=0.02), New York Heart Association class III or IV (<i>p</i>=0.02), a preoperatively unidentified pathogen (<i>p</i>=0.02) and concomitant operation for abscess and fistula (<i>p</i>=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (<i>p</i>=0.11). Multivariate analysis revealed that NYHA III-IV(<i>p</i>=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (<i>p</i>=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

A Case of Valve Repair in Mitral Valve Regurgitation Associated with Acromegaly and a Review of the Literature during the Last 2 Decades / 日本心臓血管外科学会雑誌

Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. A 62-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet, which was successfully repaired. At the age of 57 years, the patient was admitted due to heart failure without valvular disease. Acromegaly was diagnosed and a pituitary tumor was removed surgically. At the age of 62, a heart murmur was found, and moderate to severe MR was diagnosed. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. Histological examination showed myxomatous degeneration. The patient recovered uneventfully. During the last 2 decades, only 21 surgical cases of valvular disease associated with acromegaly were reported in the literature; mitral valve lesions in 10 patients (all with regurgitation), aortic valve lesions in 10 patients (7 with regurgitation and 3 with stenosis), and one with combined lesions of mitral and aortic valves. Since histology did not show specific changes in many reports, it is still unclear whether valve lesions are caused by a high GH hormone level. Although mitral valve replacement was recommended in the 1990s due to the fragility of valvular rings and their apparatus, mitral repair was performed in 5 recent cases and no recurrence has been reported.

A Report of Successful Treatment of an Infectious Pseudoaneurysm after Graft Replacement of the Ascending Aorta / 日本心臓血管外科学会雑誌

A 74-year-old woman was admitted to our hospital with a diagnosis of a pseudoaneurysm 5 months after graft replacement of the ascending aorta, and underwent re-replacement employing left ventricle venting through a left anterior thoracotomy. Culture of the thrombi in the pseudoaneurysm revealed Psuedomonas infection. On the 11th postoerative day, a single-stage procedure of irrigation, debridment, and immediate closure with omental transposition was performed. Although the chest CT scan 1 month after the omental transposition revealed a residual abcess, it was completely obliterated after 2 months without further operation.

Replacement of the Ascending Aorta and the Transverse Aortic Arch for Chronic DeBakey Type I Dissecting Aneurysm in a Patient with Aberrant Right Subclavian Artery / 日本心臓血管外科学会雑誌

We report a case of chronic DeBakey type I dissecting aneurysm with an aberrant right subclavian artery, in which replacement of the ascending aorta and the transverse aortic arch was performed under selective cerebral perfusion, resulting in complete obliteration of the false channel in the descending thoracic aorta. A 57-year-old female was admitted to our service complaining of chest and back pain. An aberrant right subclavian artery that originated from the descending thoracic aorta was identified. During operation, the dissected aortic wall of the aortic arch and the proximal descending thoracic aorta that involved more than half of its circumference was resected, the dissected intima was reapproximated at the distal stump, and the beveled distal end of the tubular ascending aortic prosthesis was secured to the cut edge. The postoperative course was uneventful, and she is leading a normal life now four years after surgery. It is rare to reconstruct the aortic arch for aortic dissection that occurred in a patient with aberrant right subclavian artery, and the technical details were reported.