The Effectiveness of Left Side Pericardiotomy in Off-Pump Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

In off-pump coronary artery bypass grafting (OPCAB), adequate exposure under stable hemodynamic condition is mandatory. We introduced left side pericardiotomy to expose the left anterior descending artery without lifting up the ventricle in 2008. With this pericardiotomy approach, the exposure of the circumflex and right coronary artery territory became easier and OPCAB with left side pericardiotomy was compared with OPCAB with midline pericardiotomy. From 2004 to 2011, 194 elective first time coronary artery bypass grafting (CABG) were performed in our hospital. Before 2008, 62 patients underwent OPCAB with midline pericardiotomy which constituted 61% of the CABG in that period. After 2008, the pericardium was dissected on the left side and a small pericadiotomy was made on the left side of the main pulmonary artery. This incision was then extended to the apex. With this pericardiotomy, only two patients underwent CABG with cardiopulmonary bypass (one patient with 15% left ventricle ejection fraction and one more patient who developed acute coronary syndrome during anesthesia induction). Thus 91 out of 93 patients underwent OPCAB (98%) (Group L). In Group L, old myocardial infarction and unstable angina patients were frequent. The frequency of the patients with left ventricular ejection fraction less than 40% tended to be more in Group L. The operation time was significantly shorter in Group L (Group M 305±71 min, Group L 223±54, <i>p</i><0.0001) and the number of distal anastomoses number was significantly more in Group L (Group M 2.3±0.7, Group L 2.8±1.0, <i>p</i><0.0001). Blood pressure during left circumflex coronary artery and right coronary artery anastomosis was significantly higher in Group L, and even continuous dopamine infusion requirement was significantly less in Group L (92% in Group M, 13% in Group L, <i>p</i><0.001) among the patients with left ventricle ejection fraction less than 60%. There was only 1 hospital death in Group M. Postoperative maximum CK-MB was significantly lower in Group L (Group M 48±107 IU/<i>l</i>, Group L 13±16 IU/<i>l</i>, <i>p</i>=0.005) and the patients with CK-MB more than 12 IU/<i>l </i>was significantly frequent in Group M (Group M 73%, Group L 33%, <i>p</i><0.0001). Postoperative ICU and hospital stay period was significantly shorter in Group L (ICU stay : Group M 3.4±2.3 days, Group L 2.0±1.4 days, <i>p</i><0.0001, hospital stay : Group M 27±21 days, Group L 16±7 days, <i>p</i><0.0001). The patency of the graft to the left anterior descending artery did not differ significantly (Group M 94%, Group L 99%), however the patencies of the grafts to left circumflex artery and right coronary artery were significantly better in Group L (left circumflex artery : Group M 75%, Group L 98%, <i>p</i>=0.001, right coronary artery : Group M 81%, Group L 98%, <i>p</i>=0.014). Left side pericardiotomy seemed to be useful because OPCAB with left side pericardiotomy yielded shorter operation time, less myocardial enzyme release, improved postoperative recovery and better patency of graft to the left circumflex and right coronary artery.

A Case of Thoracic Endovascular Aortic Repair with Fenestrated Stentgraft for Ulcer-like Projection of the Proximal Anastomosis after Total Arch Replacement for Acute Type A Aortic Dissection after Open Heart Surgery / 日本心臓血管外科学会雑誌

We report a case of thoracic endovascular aortic repair (TEVAR) with a fenestrated stent graft for ulcer-like projection (ULP) of the proximal anastomosis after total arch replacement (TAR) for acute type A aortic dissection (DAA). A 73-year-old woman with a history of surgical resection of a left atrial myxoma in January 2009 underwent TAR for DAA in November 2011. The contrast enhanced CT (CE-CT) 72 days after TAR revealed two ULPs anterior and posterior to the proximal anastomosis. Surgical repair would be difficult because of the history of cardiac and aortic surgery, therefore TEVAR with a fenestrated stent graft was performed. The postoperative course was uneventful and she was discharged on the 8th postoperative day. The CE-CT 3 months after TEVAR showed almost completely thrombosed ULPs. Endovascular repair with fenestrated stent graft for the proximal anastomotic ULP can be a useful and effective treatment.

Endovascular Abdominal Aortic Aneurysm Repair with on Excluder for Proximal Neck Angulation / 日本心臓血管外科学会雑誌

The results of endovascular abdominal aortic aneurysm repair (EVAR) for severe neck angulation with an Excluder were evaluated. We performed EVAR in 51 patients, using an Excluder, from September 2007 to September 2011. The angle between proximal neck and the aneurysm (Angle) was less than 61° in 31 patients (Group I), 61-90° in 13 patients (Group II) and more than 90° in 7 patients (Group III). In Groups I and II, the angled proximal neck was straightened with a stiff guide wire and a Trunkipsilateral device was deployed slowly (aortic modification technique). In Group III, the device modification technique was applied. In this technique, the stiff guide wire was inserted in the aortic root. The Trunkipsilateral device was bent to the contra lateral limb side and was inserted into the aorta. The stiff guide wire was pushed in with a fulcrum at the aortic valve. This procedure resulted in bending of the wire and the trunk-ipsilteral device became parallel to the proximal neck. The renal artery position was confirmed on angiographys and the main body was deployed slowly. We performed angiography after planned device deployment to evaluated Type Ia endoleak, and if it was observed, an additional procedure such as Aortic Extender or Palmaz XL stent deployment was performed and the Type Ia endoleak was evaluated during the procedure by completion angiography. The Angle change was measured by enhanced CT at 7 days and 6 month after EVAR. The Angle were 97-137° in Group III. The frequency of Type Ia endoleak after planned device deployment (35% in Group I, 55% in Group II and 17% in Group III), additional procedure for Type Ia endoleak (29% in Group I, 23% in Group II and 14% in Group III) and Type Ia endoleak by completion angiography (0% in Group I, 8% in Group II and 14% in Group III) did not differ significantly between the 3 groups. When Group I was sub divided into those with Angle less than 41° (Group Ia, 15 patients) and those with an Angle from 41 to 60° (Group Ib, 16 patients), Type Ia endoleak after planned device deployment (18% in Group Ia, 63% in Group Ib) was significantly more frequent in Group Ib and the additional procedure for Type Ia endoleak (7% in Group Ia, 50% in Group Ib) was more frequent in Group Ib. The Angle significantly decreased 7 days after EVAR and did not change thereafter in all 3 groups. EVAR with an Excluder for severe neck angulation was feasible by device modification with the bending technique. This technique might be useful for patients with an Angle of more than 41°.

Endovascular Therapy for Aortic Emergency / 日本心臓血管外科学会雑誌

Aortic emergencies are surgically challenging and the mortality rate remains high. Since December 2003, we have performed endovascular treatment with a stent graft (EVT) in 15 cases of aortic emergency, including 8 cases of aortic rupture or traumatic aortic disruption, 1 case of traumatic iliac artery disruption, 3 cases of aortobronchial fistula (ABF), and 3 cases of aortoenteric fistula (AEF). In 9 cases of aortic rupture and traumatic aortic or iliac disruption, 1 patient died due to traumatic cerebral hemorrhage, but the remaining 8 patients were discharged without complications. While hemoptysis was resolved in all 3 patients with ABF, 1 patient with primary ABF died due to pneumonia, and 1 patient with secondary ABF died due to multiple organ failure. Furthermore, 1 patient with primary AEF progressed well without any evidence of postprocedural stent graft infection. In 2 patients with secondary AEF, both required secondary surgical graft excision, and 1 of these died due to the recurrence of infection. EVT has shown good results in hemostasis for aortic emergency. However, if a source of infection persists, secondary surgical intervention is required in some cases. Commercially available endovascular stent graft make it possible to treat tortuous segments of the thoracic aorta and the abdominal aorta, therefore we expect there to be more patients with aortic emergencies who require EVT.

Thoracoabdominal Aortic Dissection in a Patient with SLE / 日本心臓血管外科学会雑誌

Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease associated with the production of various autoantibodies and involvement of multiple organs. We report that steroid therapy for the SLE might play a major role in accelerating atherosclerosis and the patient suffered an aortic dissection. A 53-year-old woman had been receiving steroid therapy for 10 years due to SLE. The patient had thoracoabdominal aortic dissection. Conservative therapy was commenced, but the diameter of the dissecting aneurysm was enlarged. Therefore, grafting for the thoracic descending aorta and the abdominal aorta was performed. The patient experienced no significant postoperative complications.

A Successful Surgical Repair for Nonpenetrating Cardiac Trauma with Concomitant Rupture of the Pericardium / 日本心臓血管外科学会雑誌

We report a case of nonpenetrating cardiac trauma successfully managed by an emergency operation. An 82-year-old woman, who was involved in a traffic accident, was transferred to our institution from a remote island in a critical condition accompanied with left hemothorax, loss of consciousness, subarachnoid hemorrhage and right humerus fracture. She was transported rapidly to the operation room, and immediate left thoracotomy revealed a small cardiac rupture on the free wall of right ventricular outflow tract with concomitant rupture of the pericardium. The wound was controlled by digital compression, and was closed with interrupted pledgeted sutures without cardiopulmonary bypass. She regained consciousness gradually although tracheotomy was needed, and was moved to another local hospital in a stable condition.

A Female Case of Abdominal Aortic Aneurysm in Association with Horseshoe Kidney / 日本心臓血管外科学会雑誌

A 65-year-old woman was referred to our department for further examination and treatment of an abdominal aortic aneurysm. Preoperative abdominal 3-D CT revealed a horseshoe kidney with 2 aberrant renal arteries, arising from bilateral common iliac arteries and supplying blood to the renal lower poles. At operation, the abdomen was explored via a long midline incision. The abdominal aortic aneurysm was replaced with a knitted Dacron bifurcation graft without symphysiotomy, and the 2 aberrant renal arteries were preserved. Postoperative 3-D CT showed no sign of renal infarction or dysfunction. Abdominal 3-D CT was useful to reveal aberrant renal arteries of the horseshoe kidney.

Pericardiectomy with Cardiopulmonary Bypass in a Case of Constrictive Pericarditis Following Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

The operation for constrictive pericarditis after coronary artery bypass grafting (CABG) needs complete pericardiectomy without injury to the bypass graft. A 60-year-old man had pleural effusion a month after CABG. Right atrial pressure (RAP), right ventricular pressure (RVP), and pulmonary capillary wedge pressure (PCWP) were elevated and RVP showed a dip and plateau sign on cardiac catheterization. We diagnosed heart failure due to constrictive pericarditis following CABG. Pericardiectomy was performed using a cardiopulmonary bypass through a median sternotomy. The Harmonic Scalpel was useful for dissecting the pericardium. After the operation, it took a month for the patient to improve. RAP, RVP and PCWP were decreasing, and the dip and plateau sign of RVP was improved. The pleural effusion disappeared and the patient was discharged on the 73rd postoperative day.

Mitral Valve Replacement 8 Years after Left Pneumonectomy / 日本心臓血管外科学会雑誌

We report mitral valve replacement (MVR) in a patient who had undergone left pneumonectomy for thoracic empyema 8 years previously. A 75-year-old man had heart failure due to mitral valve regurgitation and medication therapy was initiated. Although the heart had shifted to the right side, MVR was performed using a SJM valve with primary median sternotomy. The tracheal intubation tube was removed 17h after the operation, and the patient was discharged on the 43rd postoperative day. Careful preoperative assessment, preoperative control of heart failure, and careful attention to perioperative fluid management are important components of successful clinical management.

A Case of One-Stage Operation for Brachiocephalic Aneurysm and Aortic Regurgitation Associated with Aortitis Syndrome / 日本心臓血管外科学会雑誌

A 31-year-old woman had an aneurysm of the brachiocephalic artery and aortic regurgitation due to aortitis syndrome. As C-reactive protein (CRP) levels were high (27.5mg/dl), steroid therapy was initiated. After CRP became negative, the brachiocephalic aneurysm was repaired using a GELWEAVE^® Y-graft, and the aortic valve was replaced with an ATS^® mechanical valve. Regional cerebral oxygenation (rSO₂) was monitored during the operative period. The level of rSO₂ did not change during the period when the brachiocephalic artery was clamped, resulting in no cerebral damage after the operation. Homer's syndrome appeared after the operation but the symptoms gradually improved spontaneously. A mechanical valve was chosen because the patient did not want to undergo a reoperation. No cerebrovascular event occurred after the operation and the patient was discharged on the 28th postoperative day.

Operation with Cardiopulmonary Bypass Using Heparin and Nafamostat Mesilate for a Patient with Protamine Allergy / 日本心臓血管外科学会雑誌

A 77-year-old woman was given general anesthesia for an ascending aortic aneurysm operation and went into anaphylactic shock. The operation was canceled. Vecuronium, pancuronium, protamine and famotidine revealed positive prick test reactions. Ascending aortic replacement underwent under minimum dose of heparin for cardiopulmonary bypass (CPB). Heparin was injected immediately before CPB (2.5mg/kg) and nafamostat mesilate was injected continuously during CPB (2mg/kg/h). The ACT value was over 1, 400sec during CPB. However, protamine was not used after CPB. The operation time was 4h and 30min. CPB time was 1h and 26min. After the patient returned to the ICU, bleeding from the chest drainage tubes increased temporarily. The bleeding decreased gradually after administration of FFP and MAP.

Clinical Evaluation and Comparison of the ATS Medical Open Pivot Prosthetic Valve and St. Jude's Medical Prosthetic Valve in the Aortic Position / 日本心臓血管外科学会雑誌

The valvular function after aortic valve replacement was examined using Doppler echocardiography and changes in serum lactate dehydrogenase (LDH) and free hemoglobin levels were assessed. Data for the ATS Medical open pivot prosthetic valve were compared with those of the St. Jude's Medical prosthetic (SJM) valve, a similar bileaflet valve. These have been used in the past 5 years. There were 23 patients with ATS valves (13 men and 10 women, with a mean age of 60.4±13.8 years) and 16 patients with SJM valves (10 men and 6 women, with a mean age of 61.4±8.7 years). The left ventricular diastolic diameter index (LVDdI), left ventricular systolic diameter index (LVDsI), % fractional shortening (%FS) and left ventricular mass index (LVMI) were determined by echocardiography. The peak pressure gradients of the aortic prosthetic valves were calculated by a simplified Bernoulli equation. Postoperative LVDdI, LVDsI and LVMI were not significantly different in the ATS group and the SJM group. However, the %FS of the ATS group was significantly higher than that of the SJM group with aortic stenosis. The pressure gradients at the aortic prosthetic valve position were not significantly different between ATS and SJM valve in the 19-mm, 21-mm and 23-mm size. Postoperative improvement or recovery of the serum LDH level was observed significantly more frequently in the ATS group than the SJM group (<i>p</i><0.005). The free hemoglobin level of the ATS group was also lower than that of the SJM group (<i>p</i><0.005). We demonstrated satisfactory valvular function of the ATS valve compared with the SJM valve. Postoperative improvement of hemolysis was observed significantly more frequently and more rapidly in the ATS valves.

A Case of Abdominal Aortic Aneurysm Surgery in a Patient with Aplastic Anemia / 日本心臓血管外科学会雑誌

A 77-year-old woman with aplastic anemia who suffered from abdominal aortic aneurysm successfully underwent aneurysmecotmy. The preoperative transfusion of G-CSF, 6 usits of red cell and 3 units of platelet restored blood analysis to a normal level prior to operation. During the operation, 840ml of blood was lost, 9 units of red cell and 6 units of FFP were transfused, and 9 units of platelets were given on the operative day. The postoperative course was uneventful.