ABSTRACT
A 79-year-old man was admitted for thoracoabdominal aortic aneurysm repair. He had already twice undergone coronary artery bypass grafting, 19 and 2 years previously. The value of the ejection fraction of the left ventricle was 36%, measured by ventriculography; and transthoracic echocardiography revealed moderate aortic valve regurgitation. In the presence of aortic valve regurgitation or coronary artery disease, myocardial perfusion under hypothermic fibrillatory arrest may be significantly impaired. Therefore, to maintain a beating heart we used separate perfusions of the upper and lower body that enabled individual temperature control of each organ. The femoral and axillary arteries were cannulated, and a long cannula was inserted into the right common femoral vein and positioned in the right atrium. Cardiopulmonary bypass was established, and the upper body was mildly cooled until the pharyngeal temperature was 33°C, while the lower body was cooled until the bladder temperature reached 20°C. Mild hypothermia of the upper body maintained the beating heart, and deep hypothermia in the lower body provided adequate protection to the spinal cord. Furthermore, in a case of aortic valve regurgitation and low left ventricular function, left ventricular venting is essential for the heart. However, it was difficult to insert the venting tube through the apex of the left ventricle or through the left inferior pulmonary vein; therefore, we selected the left main pulmonary artery for left ventricular venting, and maintained a non-working beating heart. After cardiopulmonary bypass was discontinued, cardiac function was good although a bleeding tendency became apparent. Postoperatively, the maximum dose of dopamine we needed was only 3γ. There were no remarkable complications and the patient was discharged on postoperative day 30. This experience suggests that pulmonary artery venting and separate perfusion of the upper and lower body to individually control organ temperatures is a useful procedure for thoracoabdominal aortic aneurysm repair in patients with low left ventricular function.
ABSTRACT
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.
ABSTRACT
A 74-year-old man had a right common iliac aneurysm perforating into his inferior vena cava. He showed a pulsating abdominal mass, claudication of the right leg and swelling of both legs. The fistula was preoperatively diagnosed by aortography. The fistula was closed with two interrupted 3-0 monofilament sutures with pledgets within the aneurysm, by clamping all vessels communicating to it. The aneurysm was replaced with a Y-shaped Dacron graft. The postoperative course was uneventful and the patient was discharged on the 17th postoperative day without any leg claudication or swelling of the legs. This complication is rare, with only 7 such reports in Japan. It should be surgically managed as soon as the diagnosis is confirmed. Clamping all vessels communicating to the fistula in closing it is a safe and reliable approach.