A Case of the Left Atrial Appendage Perforation with the WATCHMAN Device Implantation Rescued by an Open Heart Surgery / 日本心臓血管外科学会雑誌

The transcatheter left atrial appendage occluding device, WATCHMAN, can be used to prevent thromboembolism in patients with nonvalvular atrial fibrillation who are at high risk of bleeding during anticoagulation. We report an emergent surgical case of cardiac tamponade due to the left atrial appendage perforation with the WATCHMAN device implantation. An 83-year-old woman with recurrent paroxysmal atrial fibrillation (CHA2DS2-VASc score 4, HAS-BLED score 3) after catheter ablation was scheduled for the WATCHMAN device implantation. During implantation, the patient developed cardiac tamponade and underwent emergent surgery with cardiopulmonary bypass for active bleeding despite pericardial drainage. The bleeding was caused by the left atrial appendage perforation, and suture exclusion of the left atrial appendage was performed.

A Rare Case of Cornelia de Lange Syndrome Achieving Intracardiac Repair of Tetralogy of Fallot Following Ectopic Patent Ductus Arteriosus Banding / 日本心臓血管外科学会雑誌

We describe the case of a 1-year and 7-month-old girl who was born at 36 weeks and 6 days of pregnancy weighing 1,351 g. In addition to the diagnosis of Cornelia de Lange syndrome and Tetralogy of Fallot, we confirmed shunt blood flow from the lesser curvature of the aortic arch to the main pulmonary artery. Thus, we additionally diagnosed ectopic patent ductus arteriosus (PDA). Ultrasonography showed interruption and retrograde flow of the diastolic blood flow in the anterior cerebral artery. Therefore, we made a diagnosis of blood stealing due to an ectopic PDA, and we performed surgical intervention via a median sternotomy at 25 days. When we ligated the shunt blood vessel, the percutaneous oxygen saturation decreased from the high 90% range to the low 70% range, thus we temporarily released the ligation. We narrowed the ectopic PDA so that the percutaneous oxygen saturation could be maintained the high 80% range. Postoperative ultrasonography showed improvement of the pressure waveform in the anterior cerebral artery. After discharge, oxygen demand increased gradually with weight gain, and we performed intracardiac repair using a monocusp valve patch at 1 year and 7 months. We report a rare case of Cornelia de Lange syndrome wherein we achieved intracardiac repair of Tetralogy of Fallot after ectopic PDA banding in the neonatal period.

Two Stage Operation for Chronic Dissecting Thoracic Aortic Aneurysm Associated with True Lumen Obstruction of the Abdominal Aorta / 日本心臓血管外科学会雑誌

A 64-year-old man who had chronic aortic dissecting aneurysm with true lumen obstruction of the abdominal aorta was referred to our hospital for surgery. He underwent total aortic arch replacement with the elephant trunk technique using an aortofemoral artery bypass as a first-stage operation. Reconstruction of the thoracic aortic descending aneurysm using the previous elephant trunk graft in a second-stage operation was feasible. His perioperative course was uneventful and he had no neurologic complications.

Left Subclavian Artery Arising from Kommerell's Diverticulum of a Left High Aortic Arch / 日本心臓血管外科学会雑誌

A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm (50 mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell's diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.

In Situ Reconstruction with a Rifampicin-Bonded Gelatin-Sealed Dacron Graft for Pseudoaneurysm after Root Replacement / 日本心臓血管外科学会雑誌

A 58-year-old man underwent aortic root replacement for annuloaortic ectasia (AAE) and aortic regurgitation (AR). The patient was readmitted because of chest discomfort 3 months after the first operation. Computed tomography showed a pseudoaneurysm of the ascending aorta. Re-aortic root replacement was done on an emergency basis. However, 16 days after the second operation, a pseudoaneurysm was revealed by computed tomography. The third operation was successfully performed using a rif ampicin-bonded gelatin-sealed Dacron graft (GELSEAL^®; Sulzer Vascutek, Glasgow, UK). The postoperative course was uneventful.

Surgical Salvage of Acute Pulmonary Thronrboembolism Supported by a Percutaneous Cardiopulmonary Bypass System / 日本心臓血管外科学会雑誌

We report a 66-year-old woman with circulatory collapse due to acute pulmonary thromboembolism, in whom a left nephrectomy for a renal tumor was scheduled. Following preoperative renal angiography. The patient suffered sudden shock resulting from pulmonary thromboembolism (PTE) following release of compression of the puncture site. The patient was transported to the ICU, and percutaneous cardiopulmonary support (PCPS) was instituted immediately for resuscitation. Hemodynamics were stabilized by PCPS and percutaneous thrombectomy was attempted. However, perforation by a catheter inverted to the extracardiac space occurred, which neccesitated emergency surgical hemostasis. PCPS was converted to cardiopulmonary bypass (CPB). The injured right ventricle and right atrial walls were repaired, and pulmonary thrombectomy was performed via the pulmonary trunk. CPB was easily terminated and her postoperative course was uneventful with anticoagulant therapy. Left nephrectomy was performed two months later. PTE recurred due to the interruption of anticoagulation for surgical treatment of a renal tumor. Percutaneous pulmonary thrombectomy and thrombolysis therapy were effective and a Greenfield filter was inserted into the inferior vena cava to prevent recurrence.