A Case of Perigraft Seroma after Ascending Aorta Replacement That Was Cured by an Omental Pedicle Graft / 日本心臓血管外科学会雑誌

A 40-year-old man with a family history of Marfan syndrome was admitted to our hospital because of acute Stanford type A aortic dissection. He underwent a Bentall operation with an artificial vascular graft. Postoperative computed tomography revealed a low-density area around the graft in the ascending aorta and at the left subclavian artery cannulation site. He showed no symptoms and was discharged uneventfully. Five months after the operation, a pulsatile subdermal tumor appeared in the center of the median sternotomy. Computed tomography showed low- and high density fluid accumulation surrounding the ascending aortic graft, and this was connected with a subdermal tumor. We suspected collapse of the anastomotic site and performed an emergency operation. The fluid around the aortic graft was clear and diagnosed as perigraft seroma. To prevent recurrence, we filled the space around the aortic graft with an omental pedicle graft. After the operation, perigraft seroma did not recurr. In addition, with the disappearance of the seroma in the mediastinum, fluid accumulation at the left subclavian artery cannulation site also disappeared.

Multidetector CT in detection of troublesome posterior sectoral hepatic duct communicating with cystic duct.

OBJECTIVE: To investigate whether multiple detector CT (MDCT) could detect troublesome aberrant posterior sectoral hepatic duct (PHD) communicating with cystic duct (CD). METHODS: The most troublesome bile duct anomaly during cholecystectomy is an aberrant PHD communicating with CD. It has been suggested that an unenhanced small duct between Rouviere's sulcus and CD on MDCT could be coincident to an aberrant PHD communicating with CD. A total of 224 patients who underwent laparotomy with complete lymph node dissection in the hepatoduodenal ligament for hepatobiliary or pancreatic tumour were enrolled. Retrospective review of preoperative MDCT images and surgical records was performed. RESULTS: Preoperative MDCT detected 8 (3.6%) unenhanced ducts between Rouviere's sulcus and CD. Surgical records identified 7 (3.1%) cases of aberrant PHD communicating with CD, and all 7 cases showed an unenhanced duct between Rouviere's sulcus and CD on preoperative MDCT imaging. Among the 7 patients, 5 (71%) were without bile duct dilatation. CONCLUSION: MDCT could detect troublesome aberrant PHD communicating with CD, regardless of the presence or absence of bile duct dilatation. Advances in knowledge: MDCT could detect most troublesome PHD communicating with CD, regardless of the presence or absence of bile duct dilatation.

Aortic Valve Reconstruction (AVrC) Using Autologous Pericardium for a Patient with Severe Aortic Stenosis and Chronic Renal Failure Prior to Kidney Transplant Surgery / 日本心臓血管外科学会雑誌

We performed aortic valve reconstruction (AVrC) using autologous pericardium for a patient with severe aortic stenosis and chronic renal failure, prior to kidney transplantation. The patient received kidney transplantation in the early phase after cardiac surgery. The case was a 61-year-old man with severe aortic valve stenosis who received dialysis due to chronic renal failure. We performed AVrC using autologous pericardium for the following reasons. Anticoagulant therapy is not desirable because of the need to perform kidney transplantation in the early phase after cardiac surgery. Implantation of prosthesis was not desirable because the patient requires oral immunosuppression therapy after kidney transplantation. There was no significant postoperative pressure gradient of the aortic valve orifice or aortic valve regurgitation (AR). The patient received kidney transplantation 113 days after surgery. AVrC using autologous pericardium was feasible for aortic stenosis patients in a patient waiting to receive kidney transplantation because anticoagulation therapy is not necessary after AVrC.

Preoperative Assessment of Small Saphenous-Type Varicose Veins by Three-Dimensional CT Venography with Dual-Route Injection / 日本心臓血管外科学会雑誌

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.

Current Strategies Against Infections Caused by Multidrug-resistance Bacteria / 日本農村医学会雑誌

　　Severe infections arising from nosocomically encountered gram-negative bacteria, such as extended-spectrum beta-lactamase producing bacteria and multidrug-resistant Pseudomonas are serious problems today. While carbapenems are looked upon as the preferred agents for treatment of infections caused by extended-spectrum beta-lactamase producing bacteria, carbapenemases have been recently reported. Surveillance data is needed to treat infectious diseases due to resistant organisms.

A Case of Acute Aortic Dissection Following Coronary Artery Bypass Grafting, Complicated with Upper Extremity and Bowel Ischemia / 日本心臓血管外科学会雑誌

A 65-year-old man had acute Stanford type A aortic dissection complicated with upper extremity paralysis, 7 months after coronary artery bypass grafting. The superior mesenteric artery (SMA) appeared patent on CT angiography. However, color Doppler ultrasonography revealed malperfusion of the SMA. Progressive metabolic acidosis indicated bowel ischemia. Although antihypertensive therapy was selected due to possible injury of the right internal thoracic artery (RITA) graft at thoracotomy, revascularization of the SMA and reconstruction of axillary arteries were indicated due to increased paralysis and acidosis. Following anastomosis of a saphenous vein graft between the iliac artery and the SMA, the color and movement of the small intestine apparently improved. The axillary artery was transected and reconstructed with fenestration. Metabolic acidosis improved after SMA bypass but before superior axillary artery reconstruction. Upper extremity paralysis improved. Seven days later, however, he complained of sudden onset of back pain associated with hypotension, which was due to cardiac tamponade. He underwent replacement of the ascending aorta, elevation of the aortic valve, and reimplantation of the radial artery graft. He had an uneventful postoperative course and was discharged with no remaining complaints. In this case, treatment of upper extremity and bowel ischemia was selected prior to central operation, and irreversible damage was avoided. Color Doppler ultrasonography was helpful for diagnosing bowel ischemia before progression to necrosis. It must be remembered that patency diagnosed with CT angiography does not necessarily rule out mesenteric ischemia.

Femoro-Femoral Bypass Anterior to the Pubis and Inside of the Thigh Muscle for Treatment of Suspected Infected Aneurysm in the Ilio-Femoral Area / 日本心臓血管外科学会雑誌

Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.

Atrial contraction after surgical isolation of the left atrial posterior wall concomitant with mitral valve replacement.

BACKGROUND: Surgical isolation of the left atrial posterior wall (LA-PW isolation) can terminate chronic atrial fibrillation associated with mitral valve disease. However, atrial contraction after LA-PW isolation has not been evaluated. METHODS AND RESULTS: The study group comprised 14 patients (mean age, 63+/-14 years) with mitral valve disease who recovered and maintained regular sinus rhythm after LA-PW isolation. Before the procedure, and 2-3 weeks and 1 year after the LA-PW isolation, the patients underwent an echocardiographic study. The left atrial (LA) diameter decreased after the LA-PW isolation and the change became significant 1 year later (before: 50.1+/-5.1 mm, after 2-3 weeks: 46.0+/-4.9 mm; p<0.05, after 1 year: 44.0+/-6.1 mm; p<0.05 vs before the operation). The left ventricular (LV) end-diastolic diameter, LV ejection fraction and LV fractional shortening did not change significantly from before the LA-PW isolation and after 1 year. The time - velocity integral of the atrial wave (Ai) and atrial filling fraction significantly increased (Ai: 4.5+/-2.1 cm vs 5.8+/-2.3 cm; p<0.05; atrial filling fraction: 15.4+/-7.7% to 19.2+/-8.3%; p<0.05) during the follow-up period. CONCLUSION: LA-PW isolation can benefit the restoration of regular sinus rhythm and, furthermore, the recovery of atrial contraction.

A Case of Redo Below-Knee Femoro-Popliteal Bypass Utilizing Segmental Patent Saphenous Vein Graft / 日本心臓血管外科学会雑誌

A 73-year-old man underwent initial below-knee femoro-popliteal bypass (FPBK) using an autologous saphenous vein graft (SVG). Six years later, a sudden leg pain developed in his right lower extremity and an emergency angiography disclosed total occlusion of the external iliac artery as well as SVG. Because sufficient arterial perfusion was not obtained even after emergent thrombectomy, redo FPBK was performed using a synthetic graft. For the distal anastomosis, we reused a segment of the previous patent SVG that had been still open at the distal anastomotic site. After cutting down the SVG at the non-thrombosed part, which was 1cm long from the distal anastomosis, 6mm ringed expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the stump in an end-to-end fashion. The proximal anastomosis was completed between the ePTFE graft and common femoral artery in an end-to-side fashion. The postoperative angiography demonstrated no stenosis of the distal anastomotic site and no occlusion of previous SVG. In a patient requiring redo FPBK, if previous SVG is not completely thrombosed at the distal anastomotic site, reutilizing the graft is one of the options to complete the redo operation in a safe and simple way. Because the long term patency of this type of composite graft has not been established, further careful observation is needed.

Late Aortic Root Redissection Following Surgical Repair for Acute Aortic Dissection Using Gelatin-Resorcin-Formalin Glue: Report of 2 Cases / 日本心臓血管外科学会雑誌

Gelatin-resorcin-formalin (GRF) glue has been generally applied in the surgical treatment of acute aortic dissection. Recently, midterm or late redissection and false anastomotic aneurysm following the use of this adhesive have been reported in several articles and the toxicity of its component has been suggested to be involved in this complication. We herein report 2 cases of aortic root redissection a few years after the initial surgery for type A acute aortic dissection. In another hospital, a 57-year-old man had undergone total arch replacement for acute dissection in which the proximal end was repaired using GRF glue. The aortic root was revealed to be redissected by computed tomography (CT) 2 years after the intervention and continued to enlarge since then. This aortic complication was treated by composite graft replacement. The intraoperative findings of marked degeneration in dissected root tissue were impressive. The other patient was a 71-year-old man. He had undergone prosthetic replacement of the ascending aorta associated with aortic valve resuspension using GRF glue for acute dissection. Three years later, symptoms of cardiac failure due to aortic regurgitation (AR) occurred and necessitated surgical correction. The AR was due to the redissection of the non-coronary cusp sinus. Repair of the coronary sinus and aortic valve replacement was performed. The postoperative course was uneventful in both cases. Other papers have cautioned that this tissue adhesive should not be used in aortic valve resuspension. Intensive long-term follow-up is required for aortic dissection patients surgically treated using this glue.

An Implantable Cardioverter-Defibrillator Rescued a Patient from Potentially Lethal Arrhythmias after Partial Left Ventriculectomy / 日本心臓血管外科学会雑誌

A 36-year-old man underwent partial left ventriculectomy (PLV) to treat end-stage dilated hypertrophic cardiomyopathy. Mitral valve replacement and tricuspid valve annuloplasty were performed to correct the mitral and tricuspid valve insufficiency. The patient suffered ventricular tachycardia and ventricular fibrillation (VT/VF) soon after surgery, but antiarrhythmic-drug therapy was sufficiently effective to treat the VT/VF. On the third postoperative day, an implantable cardioverter-defibrillator (ICD) was implanted to prevent these arrhythmias. Two months later after his discharge from the hospital, recurrent VT/VF appeared and was supposedly associated with renal failure. Continuous hemodialysis was efficacious to ameliorate the systemic circulation, and ventricular arrhythmias disappeared. He survived due to 18 ICD shocks. In appropriately selected patients, ICDs have been recognized as one of the cost-effective therapeutic options. ICDs might be recommended for patients in the postoperative period of PLV who have potentially lethal ventricular arrhythmias resistant to antiarrhythmic-drug therapy.

A Case of Reoperation for a Starr-Edwards Ball Valve Prosthesis Implanted in the Aortic Position 29 Years Previously / 日本心臓血管外科学会雑誌

A 53-year-old woman had dyspnea on effort since half a year previously and was categorized as NYHA II. She had suffered from chronic atrial fibrillation (AF) for three years. She had undergone aortic valve replacement using a Starr-Edwards ball valve (SEV) for aortic regurgitation and mitral commissurotomy for mitral stenosis 29 years previously. Echocardiography revealed mitral stenosis with an orifice area of 0.9cm² and neither dysfunction of the SEV nor abnormal findings on the valve itself. She underwent mitral valve replacement and left atrial maze procedure for AF. Because of the intraoperative findings of the cloth wear-covered SEV cage, redo aortic valve replacement was performed simultaneously. St. Jude Medical valves were used for valve prostheses. There was no complication and the ECG returned to sinus rhythm postoperatively. These has been no report of a patient with such a long period between SEV implantation and replacement in Japan. This experience made us realize again the importance of attention to the cloth wear covered cage during long term follow up for SEV.

A Case of Aortitis Syndrome Associated with Occlusion of All Arch Branches and Atypical Aortic Coarctation / 日本心臓血管外科学会雑誌

A 61-year-old man was admitted with acute cardiac failure associated with atypical aortic coarctation and severe left ventricular hypertrophy. Angiography and MRI showed that all branches from the aortic arch were occluded, and that cerebral circulation was supplied via collateral flow from small aortic branches either proximal or distal to the coarctation and by the right vertebral artery receiving retrograde flow from the right internal thoracic and right thoracodorsal arteries. Cerebral CT revealed massive cerebral infarction in the perfusion area of the right mid-cerebral artery. Aortitis syndrome was diagnosed from these findings, and ascending-abdominal aortic bypass grafting with aorto-right subclavian bypass was performed after successful conservative treatment for cardiac failure. Because of remarkable increase in the aortic blood pressure on partial clamping of the ascending aorta, proximal aortic anastomosis was performed under extracorporeal circulation. Near infrared spectroscopy (NIRS) was used to monitor the intraoperative cerebral circulation. The perfusion flow rate was maintained in order not to reduce the regional brain oxygen saturation below the critical level. No cerebral complication was encountered postoperatively. Cases of aortitis syndrome with occlusion of all arch branches are rare. NIRS was suggested to be useful to evaluate cerebral circulation during operation in such cases in which cerebral blood flow can be severely affected.

A Translocated Bentall's Procedure for Annuloaortic Ectasia Associated with Aortitis Syndrome / 日本心臓血管外科学会雑誌

A 34-year-old woman was referred to us because of severe aortic regurgitation and annuloaortic ectasia. She also showed a high level of CRP and stenosis of cervical arteries and aortitis syndrome was diagnosed. A translocated Bentall's procedure was performed after administration of corticosteroid. An SJM valve prosthesis was translocated from 1cm above the distal end of the graft and this composite graft was anastomosed to the aortic annulus with buttress sutures reinforced with Dacron felt. Both coronary orifices were reconstructed with small sized Dacron grafts, interposed from the coronary orifices to the composite graft. There was not any complication postoperatively. This procedure is preferable in cases with aortitis syndrome, because it decreases risk of prosthetic detachment in the aortic valve position.

Three Cases of Right Atrial Separation for Chronic Atrial Fibrillation with Atrial Septal Defects / 日本心臓血管外科学会雑誌

Atrial fibrillation is common in adults with atrial septal defect. A right atrial separation procedure was performed for the ablation of atrial fibrillation during the concomitant repair of atrial septal defect. The operation was performed under cardiopulmonary bypass. A Y-shape incision was made in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum. After the operation, all three patients recovered and maintained a normal sinus rhythm during follow-up periods of 12, 4, and 1 months. This is a simple and effective procedure for the elimination of chronic atrial fibrillation associated with atrial septal defects in adults.

One-Stage Operation of Annulo Aortic Ectasia Complicated with Acute Aortic Dissection of Stanford Type B / 日本心臓血管外科学会雑誌

A 51-year-old man was admitted with symptoms of sudden back pain and abdominal pain. Echocardiography and aortagraphy demonstrated enlargement of the aortic annulus, aortic regurgitation and Stanford type B aortic dissection. Since an entry of the aortic dissection was located at the root of the left subclavian artery, a one-stage operation consisting of aortic root replacement and total arch replacement was scheduled. The aortic root replacement using Piehler's modification was first performed followed by total arch replacement combining with the closure of the entry in the distal aortic arch was followed under selective cerebral perfusion. All procedures were complished through median sternotomy. The postoperative course was uneventful and aortography showed good reconstruction of the coronary arteries and the cervical arteries and thrombo-exclusion of the false lumen in the descending aorta. This method was useful for in this case of annulo aortic ectasia with Stanford type B aortic dissection.

One-Staged Operation for Juxtarenal Aortic Occlusion and Myocardial Infarction / 日本心臓血管外科学会雑誌

A 59-year-old male suffered dyspnea and ischemia of the lower limbs due to myocardial infarction (occlusion of the right coronary artery and 99% stenosis with delay in the left anterior descending artery) and juxtarenal aortic occlusion, respectively. Juxtarenal aorto-femoral bypass operation using a Y-shaped prosthesis and coronary arterial bypass grafting using the left internal thoracic artery (LITA) and right gastroepiploic artery (RGEA) were performed simultaneously. As the left internal thoracic artery was the route of collateral blood flow to the left lower limb, aorto-femoral bypass was initially made prior to aorto-coronary bypass operation. Because of complete obstruction of the abdominal aorta and juxtarenal lumbar arteries, neither hemodynamic changes nor bleeding occurred during the reconstruction of the abdominal aortic occlusion in spite of severe coronary disease. This procedure was useful for protection of limb ischemia and shortage of extracorporeal circulation time, in addition to producing a route for insertion of an intraaortic balloon pumping catheter.

Selection of Operative Adjunct for Distal Arch Aneurysm / 日本心臓血管外科学会雑誌

We have operated upon 17 cases of distal arch aneurysm, including 3 cases of rupture, during the past 6 years. Operative adjuncts during aortic cross clamping were left heart bypass with a centrifugal pump (LHB, 6 cases), retrograde cerebral perfusion (RCP, 5 cases) and selective cerebral perfusion (SCP, 6 cases). LHB was applied to localized, the aneurysm apart from the left subclavian artery. It was safely performed during operation, but cerebral embolism happened in 2 cases with aortic cross clamping. RCP was performed in emergency cases of rupture or impending rupture. Recently 3 cases were operated by left thoracotomy under RCP. One case, an 85-year-old female, was perfused for 100min by RCP, became unconsciousness and died by multiple organ failure. Although this method was simple and easy to prepare, the efficacy of cerebral perfusion is unclear and a perfusion time of less than 90min is thought to be safe. SCP was performed in 6 cases of large aneurysm, including four cases of total arch replacement. There was one operative death, but minimum complications in the survivors. Distal arch aneurysm varies in shape, location and size. Operative adjunct must be selected based on the condition of the aneurysm.

Left Thoracotomy before Laparotomy for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Twelve cases of ruptured abdominal aortic aneurysm (RAAA) were treated during 5 years. Nine showed severe hypotension (systolic pressure below 70mmHg) and three required cardiac massage prior to operation. At the beginning of this study, direct laparotomy was conducted on 4 cases but mortality was high mortality (75%). Left thoracotomy with antero-lateral incision through the 7th intercostal space was carried out to access the thoracic aorta for clamping before laparotomy, since the major mortality of this disease is due to abrupt bleeding following anesthesia and operation. Left thoracotomy before laparotomy was conducted on 8 cases, half of whom required aortic clamping during operation (clamping time 21min). Operative mortality following thoracotomy decreased (12.5%). The aneurysm size and the time of operation for the groups with or without thoracotomy were the same, though the degree of bleeding significantly differed (3, 925ml in the group with thoracotomy, 7, 193ml in the group without thoracotomy). Left thoracotomy befor laparotomy obtained good results in case of RAAA.