A Case of Acute Type B Aortic Dissection Subsequent to Asymptomatic Chronic Type A Aortic Dissection Which Was Difficult to Distinguish from Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

Aortic dissection presents with acute chest or back pain. However, it can be asymptomatic in the acute phase with delayed symptomatic presentation or incidental diagnosis upon chest imaging. We report a case of acute type B aortic dissection subsequent to chronic type A aortic dissection which was difficult to distinguish from acute type A aortic dissection. A 45-year-old man was admitted to a hospital with sudden back pain. An enhanced chest CT revealed a suspected acute type A aortic dissection. The patient was transferred to our hospital and we performed an emergent total arch replacement. Intraoperative findings showed that there were two entries at the origin of the brachiocephalic artery and the left subclavian artery. The ascending aorta presented wall thickening but the descending aorta did not present wall thickening. Histopathologically, the adventitia was obviously thickened with dissection findings in the tunica media. Thus it was diagnosed as acute type B aortic dissection subsequent to chronic type A aortic dissection. Great caution should be taken in asymptomatic chronic aortic dissection.

A Case of Surgical Removal of an Intravascular Ultrasonography Catheter Entrapped in a Coronary Stent after Percutaneous Coronary Intervention / 日本心臓血管外科学会雑誌

Entrapment of an intravascular ultrasonography (IVUS) catheter is an infrequent but serious complication associated with percutaneous coronary intervention (PCI). We report a case of successful surgical treatment of an IVUS catheter entrapped in a coronary stent after PCI. An-80-year-old man was admitted to a hospital with sudden anterior chest pain. He underwent PCI to left circumflex branch (Cx) and left anterior descending artery (LAD), followed by IVUS to ascertain stent expansion of the LAD stent. The IVUS catheter became entangled in the stent and could not be withdrawn from the outside. The patient was transferred to our hospital for its surgical removal. For the emergent surgery, we opened the stent region in the LAD and directly removed the IVUS catheter with the twisted stent. The opened place in the LAD was directly closed. Additional coronary bypass grafting involving two vessels was performed. The postoperative course was uneventful with no graft occlusion.

Recent Surgical Results of Transverse Aortic Arch Replacement / 日本心臓血管外科学会雑誌

We report the results of aortic arch replacement in 32 patients (20 males, 12 females) with aortic arch aneurysm, including 9 emergency cases. The etiology of aneurysm was atherosclerotic aneurysm in 18 patients, pseudoaneurysm in 1 patient, and aortic dissection in 13 patients. Selective cerebral perfusion (SCP) and retrograde cerebral perfusion (RCP), which are used for brain protection during aortic arch reconstruction, were both employed in this study according to our institutional policy. RCP was started at the moment of circulatory arrest after which the aneurysm was opened. In the case of 1-branch reconstruction or hemiarch replacement, we only employed RCP. If 2-branch reconstruction or total arch replacement was needed, we switched to SCP. After the distal graft anastomosis was performed, antegrade systemic perfusion was started via the 4th branch of the graft. Subsequently, 3 arch vessels was reconstructed with rewarming to shorten the SCP time, and finally proximal graft anastomosis was performed. Distal graft anastomosis with a new technique was applied in the 10 most recent cases. The “cuff” was made at the distal anastomosis site of the graft beforehand and this “cuff” was sutured to the aortic wall in an elephant-trunk fashion. This technique was a simple approach to repairing the distal lesion and allowed easy addition of stitches in case's of bleeding. The in-hospital mortality rate was 6.3% (2 of 32 patients) and the rate of cerebrovascular accident was 6.3% (2 of 32 patients). This technique for aortic arch repair is a useful method that results in low rates of in-hospital mortality and morbidity.

A Case of Successful Treatment of Intraoperative Pulmonary Tumor Embolism Using Pulmonary Angioscopy under Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

The case involved a 73-year-old woman who underwent surgical resection for right renal cell carcinoma extending to the inferior vena cava. During surgery the tumor thrombus disappeared from the inferior vena cava. We performed transesophageal echocardiography and detected the tumor thrombus in the right ventricle. Therefore, we immediately tried to remove the thrombus using cardiopulmonary bypass. However, we could not find the tumor thrombus in the right ventricle or in the main pulmonary artery. We used angioscopy of the pulmonary artery and detected the tumor thrombus at the orifice of the inferior pulmonary artery. The tumor thrombus was removed under direct visualization. In the event of an intraoperative pulmonary embolism, simple and safe techniques for exact and rapid diagnosis are needed. Intraoperative angioscopy allows direct visualization of the pulmonary arterial branches and appears to be very useful for detection of tumor thrombi even in emergency cases.

An Operative Case of Right Coronary Artery Fistula Communicated to the Left Atrium / 日本心臓血管外科学会雑誌

We report a very rare case of a coronary artery fistula with communication between the right coronary artery and the left atrium. The patient was a 45 year-old woman admitted for evaluation of heart murmur. Selective coronary angiography demonstrated right coronary artery-left atrial fistula. The operation was indicated due to volume overload of the left ventricle. At operation, the proximal portion of the coronary fistula was successfully ligated from the epicardial side and the entrance of the fistula into the left atrium was directly closed from the inside of the left atrium under the cardiopulmonary bypass. The post-operative course was uneventful. Post-operative coronary angiography showed disappearance of the fistula. Angiography 6 months later, demonstrated that the orifice of the right coronary artery remained dilated, while the diameter of the distal site was normalized.

The Early Repair of Postinfarction Ventricular Septal Perforation Performed with Normothermic Cardiopulmonary Bypass during Beating. A Case Report / 日本心臓血管外科学会雑誌

A 60-year-old woman underwent surgical treatment of postinfarction ventricular septal perforation (VSP) in the early phase after receiving total cardiopulmonary bypass without aortic occlusion. VSP developed four days after anterior myocardial infarction. On admission, inraaortic balloon pumping was used to obtain hemodynamic stabilization. On the day of admission, emergency total cardiopulmonary bypass was performed. VSP was closed with a Dacron felt patch positioned on the left side of the septum. The anterior wall of the left ventricle was closed with Dacron felt strips and reinforced using a Gore-Tex sheet. Postoperative hemodynamics improved significantly. Although the operation while the heart was beating was difficult technically, the total cardiopulmonary bypass time of this method was not longer than that of operations under cardioplegic arrest. Further more, the area of infarction was easily distinguished by color and bleeding. The surgery during normothermic heart beat was effective in preventing further ischemia of the myocardium. The surgical treatment of VSP in the early phase during normothermic heart beat under total cardiopulmonary bypass was considered to be more effective and safer than operations under cardioplegic arrest.