Circular Left Atrial Resection Technique for Left Atrial Volume Reduction in Children : Report of Two Cases / 日本心臓血管外科学会雑誌

Giant left atrium (LA) in association with mitral valve disease is a significant risk factor for mortality and morbidity. It may cause obstruction of the bronchus, pulmonary artery, inferior vena caval orifice, or left ventricle, and has also required prolonged hospital stay. We describe our experience of left atrial reduction by means of circular LA resection concomitant with mitral valve plasty in 2 children with severe mitral regurgitation (MR) and giant LA. Case 1 was a 1-year-old boy, who had severe MR and giant LA, presenting with left bronchial obstruction. He underwent mitral valve plasty and circular LA resection. His LA volume, which was calculated using enhanced chest CT examination, was decreased by 23% postoperatively, comparing that before the operation. The cardiothoracic ratio on chest X-ray changed from 60% to 49%, and his sequential symptoms from giant LA disappeared. His postoperative course was uneventful and he was discharged on postoperative day 21. Case 2 was a 12-year-old girl with severe MR and giant LA. Her LA together with the sternum and spine compressed the right atrium and caused right heart failure. She underwent mitral valve plasty and circular LA resection. Her LA volume was decreased by preoperative 22%. Cardiothoracic ratio on chest X-ray changed from 63% to 57%. Her sequential symptoms from giant LA disappeared. Her postoperative course was uneventful and she was discharged 28 days after the operation. The circular LA resection technique reduced LA volume effectively, and the patients became free of clinical symptoms. Even in children, this procedure should be indicated in selective cases who presented clinical symptoms caused by the expanded LA.

A Case of Primary Chylopericardium in Which Three-Dimensional Computed Tomography Scan with Lymphangiography Was Useful / 日本心臓血管外科学会雑誌

A 36-year-old previously healthy woman with cardiomegaly on a routine chest X-ray was given a diagnosis of primary chylopericardium after pericardial puncture revealed milky effusion. Endoscopy-assisted ligation of the thoracic duct and creation of a pericardial window was performed. The operation was greatly facilitated by the preoperative three-dimensional CT scan with lymphangiography that precisely demonstrated the distribution of the thoracic duct and other lymphatic ducts.

Successful Surgical Repair of Impending Rupture of a Pseudoaneurysm of the Brachiocephalic Artery with Prior Reconstruction of the Carotid Artery / 日本心臓血管外科学会雑誌

We report the successful repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery (BCA) in a 70-year-old man. He had undergone a mediastinal tumor resection through a median sternotomy in 1995. Pathological examination revealed non-Hodgkin's lymphoma. Two years later, he underwent radiation therapy of 65 Gray for metastasis to the supraclavicular lymph nodes. On January 18, 2000, plastic surgeons planned to perform a pectoralis major musculocutaneous flap to repair a radiation skin ulcer. During the operation, the BCA was lacerated, possibly in an area of radiation tissue damage. We performed a prosthetic graft (10-mm Gelseal^TM) replacement of the BCA. The right subclavian artery had to be ligated. Postoperative digital subtraction angiography (DSA) showed excellent reconstruction of the artery. Magnetic resonance angiography of the brain showed a deficit in the anterior communicating artery and stenosis of the posterior communicating artery, which indicated that the reconstruction procedure was reasonable. Seven months later, on August 18, 2000, the patient was transferred to our hospital because of swelling of the right neck and oozing from the previous cutaneous wound. CT scan and DSA demonstrated the presence of a pseudoaneurysm of the proximal anastomosis site, which required emergency surgery. Before this third sternotomy, a saphenous vein graft was interposed between both external carotid arteries. Removal of the prosthetic graft and resection of the pseudoaneurysm were performed under mild hypothermia and cardiopulmonary bypass with left common carotid arterial perfusion. Then, the wound was closed completely using a left pectoralis major musculocutaneous flap. The postoperative course was uneventful and DSA showed good patency of the graft and intracranial arteries. The patient was discharged without neurological complications. We conclude that prior reconstruction of the carotid artery is a safe and effective procedure for patients with aneurysmal changes in the BCA, especially in the case of re-operation.