Coronary Artery Bypass Grafting Combined with Total Arch Replacement for Severe Coronary Disease Complicated with Multiple Arch Vessel Stenosis / 日本心臓血管外科学会雑誌

A 72-year-old man was referred to our hospital for coronary artery bypass grafting (CABG) due to asymptomatic severe coronary artery disease. A preoperative CT revealed 99% stenosis of the aberrant right subclavian artery, 90% stenosis at the origin of right common carotid artery, and 75% stenosis at the origin of the left subclavian artery. As he had high risk of a perioperative cerebral ischemic event for CABG, it was difficult to perform a carotid artery stent. We performed a total aortic arch replacement combined with CABG. The postoperative course was uneventful, and he was discharged on the 12th postoperative day.

Cardiovascular Surgery in Patients with Connective Tissue Disease / 日本心臓血管外科学会雑誌

<p><b>Background</b> : Connective tissue disease (CTD) is an idiopathic autoimmune disorder which causes systemic chronic inflammation. Inflammation causes various cardiovascular diseases. Systemic steroid use, which is usually the sole treatment for CTD, also causes arteriosclerosis. Although cardiovascular surgery is often necessary in patients with CTD, preexisting multiple organ dysfunction related to CTD, in addition to systemic administration of steroids or other immunosuppressants, is thought to increase the risk of surgery. However, little is known about how the disease process of CTD influences early and late cardiovascular surgery outcomes. <b>Methods</b> : To better understand these issues, we reviewed 31 patients with CTD (study group) and compared their outcomes to those of other patients (control group) who underwent cardiovascular surgery at our institution between April 2008 and November 2013. <b>Results</b> : There were 26 women and 5 men, and the average age was 64.4±16.7 years. CTD types included rheumatoid arthritis in 7 patients, systemic lupus erhythematosus in 6, aortitis syndrome in 6, polymyalgia rheumatica in 3, scleroderma in 3, polymyositis in 3, and others. The procedures included 10 valve cases, 10 coronary artery bypass grafting (CABG) or CABG-valve combination cases, and 11 isolated or complicated thoracic aortic surgery cases. Prior to undergoing these procedures, 24 patients (77.4%) were treated with steroids and/or immunosuppressant, and 6 patients had been diagnosed with interstitial pneumonia in the study group. Moreover, the rate of peripheral artery disease and carotid artery stenosis in the study group was significantly higher than that in the control group. There were no perioperative deaths in the study group. There were no significant differences in terms of major complications such as ischemic events, infection, acute kidney injury, lung injury, and others between the groups. We conducted a follow-up survey for the study group with an average period of 27.8±16.0 months. During the follow-up period, there were 4 late deaths. In addition, 8 patients required readmission, 6 for cardiovascular events and 2 for poor wound healing. All the survivors in the study group showed improved cardiac function and were in the NYHA functional class I and II. <b>Conclusion</b> : Cardiovascular surgery for patients with CTD can provide acceptable early and mid-term results.</p>

Total Aortic Arch Replacement in a Patient with a Patent Right Internal Thoracic Artery Graft Crossing between the Sternum and the Ascending Aortic Aneurysm / 日本心臓血管外科学会雑誌

We report a case of 76 year-old woman who had previously undergone coronary artery bypass grafting (CABG) with the right internal thoracic artery (RITA) bypassed to the left anterior descending artery. Six years after CABG, she developed acute type A aortic dissection, and she was medically treated because the false lumen was thrombosed and it was considered that surgical intervention would be high risk for the patent RITA graft crossing between the sternum and the ascending aorta. During follow-up, her aortic aneurysm enlarged to 57 mm in diameter, and finally she was referred to our hospital for surgical intervention. In this case, preservation of the patent RITA graft was thought to be critical because the RITA graft was the only blood source for the left anterior descending artery. Prior to re-median sternotomy, we performed a right anterior minithoracotomy to make sufficient space between the sternum and the RITA graft, and then instituted peripheral cardiopulmonary bypass to decompress the heart. After re-sternotomy, we ensured minimum dissection of the RITA graft, and we successfully accomplished graft replacement of the ascending aorta to the aortic arch without injuring the patent RITA graft. In cases with a patent RITA graft and an ascending aortic aneurysm close to the sternum, our strategy is considered to be efficient for re-median sternotomy.

Hemolytic Anemia after Mitral Valve Surgery / 日本心臓血管外科学会雑誌

<b>Objective</b> : The aim of this study is to describe a series of patients undergoing reoperation due to hemolytic anemia after mitral valve surgery and assess the mechanisms and surgical outcomes. <b>Methods</b> : Between 2009 and 2014, we performed redo mitral valve surgery in 11 patients who had refractory hemolytic anemia after mitral valve surgery at Kyoto University Hospital. The mean age of the patients was 72.2±6.8 years old, and there were 5 men. <b>Results</b> : Preoperative echocardiography demonstrated that only 3 patients had ≥ grade 3 mitral regurgitation (MR), the rest of the patients had only mild to moderate MR. The mechanisms of severe hemolysis included paravalvular leakage (PVL) after mitral valve replacement (MVR) in 8 patients, structural valve deterioration (SVD) after MVR using a bioprosthesis in one, and residual/recurrent mitral regurgitation after mitral valve plasty (MVP) in two. All the patients except one (re-MVP) underwent MVR. The mean interval between previous operation and current operation was 14.1±9.4 years in post-MVR cases, and 2.0±1.9 years in post-MVP cases. There were three late deaths, one of which was due to cardiac death (exacerbation of heart failure due to pneumonia). There was one patient who required re-MVR for recurrent hemolysis due to PVL after MVR. <b>Conclusion</b> : Although hemolytic anemia after mitral valve surgery is rare, it often requires reoperation regardless of the degree of MR at late follow-up period. Thus, patients after mitral valve surgery should be carefully followed-up.

Staged Repair for a Patient with Infracardiac Total Anomalous Pulmonary Venous Connection Complicated by Hypoplastic Left Heart Complex / 日本心臓血管外科学会雑誌

Total anomalous pulmonary venous connection (TAPVC) is rarely associated with remarkably small left heart structures. In these types of cases, the hemodynamics resembles that of hypoplastic left heart syndrome, and the treatment strategy is controversial. We present the case of a 1-day-old girl with infracardiac TAPVC, small left heart structures (hypoplastic left heart complex), bilateral superior <i>vena cava</i>, and aberrant origin of the right subclavian artery. We performed a semi-emergent first-stage open palliation for repair of TAPVC, because of pulmonary venous obstruction. We concomitantly performed atrial septal defect (ASD) enlargement and bilateral pulmonary artery banding (BPAB). The postoperative course was uneventful and the left heart structures did not grow, so we performed the Norwood procedure and placed a right ventricle-pulmonary artery shunt with a 5.0 mm artificial graft. Subsequently, the left heart structures were not suitable for biventricular repair, so we chose univentricular repair. The patient underwent a bilateral bidirectional Glenn operation and Fontan completion at 6 and 23 months of age, respectively. TAPVC repair, BPAB, and ASD enlargement are reasonable surgical options for a patient with borderline small left heart structures and TAPVC, as they enable us to wait for growth in the left heart structures and to determine whether univentricular or biventricular repair is suitable.

Aortic Valve Replacement for a Patient with Left Main Coronary Artery Stenting / 日本心臓血管外科学会雑誌

We report a case of aortic valve replacement using a bioprosthesis after coronary artery stenting in the left coronary main trunk of a 76-year-old man with symptoms of heart failure. Pre-operation studies revealed severe aortic valve regurgitation and that the left main coronary stent protruded into the aorta. Cardiac arrest was obtained with retrograde cardioplegia. Careful observation was made to avoid injury to the aortic bioprosthesis. The postoperative course was uneventful and cardiac echo graphy showed good function of the aortic valve.

A Case of Loeys-Dietz Syndrome That Caused Rapid Enlargement of the Distal Aortic Arch Following Aortic Surgery for Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

Loeys-Dietz syndrome (LDS) is characterized by vascular findings (aortic aneurysms and dissections) and skeletal manifestations. Since aortic dissection occurs at smaller aortic diameters than observed in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS. A 45-year-old man who underwent aortic valve replacement for aortic regurgitation at the age of 33 was transferred to our hospital with the diagnosis of acute aortic dissection. We performed emergeny ascending aortic replacement, and suspected LDS because of his specific physical characteristics after surgery. His postoperative course was uneventful, however, computed tomography (CT) performed at 2 weeks after operation showed the new entry at the distal anastomotic site, patent false lumen of the descending aorta and rapid enlargement of the distal aortic arch. Therefore, we performed total arch replacement with the elephant trunk method at 3 weeks after the emergency operation. Mutation of the TGFBR2 gene was found and we finally diagnosed LDS. One year after, complete thrombosis of the false lumen of the descending aorta and decrease in size of the distal aortic arch was observed by CT.

Surgical Treatment of a Caseous Calcification Lesion Which Originated from the Calcified Anterior Mitral Annulus in Patient on Chronic Hemodialysis / 日本心臓血管外科学会雑誌

We report a case of a caseous calcification lesion originating from a calcified anterior mitral annulus. A 59-year-old woman on chronic hemodialysis was referred to our hospital due to an elevated brain natriuretic peptide value. Transthoracic echocardiography demonstrated moderate aortic valve stenosis with regurgitation and a pendulous mass in the left ventricular outflow tract, and therefore we perfomed. The patient underwent resection of the mass with aortic valve replacement. Pathological examination of the mass revealed interstitial calcium deposits but without tumors or inflammatory cells. We speculated that the cardiac mass was caseous calcification which originated from a severely calcified mitral annulus based on its echocardiographic and pathological features.

A Case of Infective Endocarditis in Which Surgical Removal of Both Eyes Was Inevitable because of Bacterial Endopthalmitis / 日本心臓血管外科学会雑誌

Bacterial endopthalmitis is associated with risk for poor visual prognosis, however, it is rarely combined with infective endocarditis. A 66-year-old man underwent pacemaker implantation and received antibiotic therapy due to persistent fever. A month after the pacemaker implantation, he was admitted to our hospital because of disturbance of vision and consciousness. Disseminated intravascular coagulation (DIC) with decrease of platelet count was also present. His eyes were reddish and swelled, and the conjunctiva were turbid and edematous in both sides. Transesophageal echocardiography demonstrated 18×13mm pendulous verruca originating from the tricuspid annulus. The patient underwent concomitant resection and repair of the tricuspid valve and removal of both infected eyes after DIC treatment. The postoperative course was uneventful and he was discharged from the hospital 43 days after the operation. We conclude that careful observation of the eyes may be needed for patients with infective endocarditis when they have some visual symptoms.

A Case Report of Double Valve Replacement for Mucopolysaccharosis with Chest Pain Attack and Severe Heart Failure / 日本心臓血管外科学会雑誌

We report a successfully treated case of double valve replacement for mucopolysaccharosis in a 27-year-old woman. Mucopolysaccharosis had been suspected since she was aged 11. Symptoms of heart failure and chest pain suggested valvular disease and she was referred to us. Echocardiography, aortography and cardioangiography showed aortic regurgitation (grade IV/IV) and mitral regurgitation (grade III/IV). She received double valve replacement and was discharged on the 38th postoperative day with symptom improvement. Although urinalysis was positive for heparan-sulfate, this case could not be diagnosed definitively as mucopolysaccharosis due to normal lymphocytic enzyme-activity. However, large amounts of mucopolysaccharoid deposits were present in her removed aortic and mitral valve leaflets, and her clinical picture corresponded with mucopolysaccharosis. Thus, it was considered that her ultimate diagnosis was combined cardiac valvular disease due to mucopolysaccharosis.

A Case of Coronary Artery Bypass Grafting Using Arterial Grafts in a Patient with Systemic Lupus Erythematosus and Review of the Literature / 日本心臓血管外科学会雑誌

We report a case of coronary artery bypass grafting (CABG) in a patient with systemic lupus erythematosus (SLE). A 24-year-old woman with SLE had been treated with steroids and immunosuppressive agents for 7 years. The patient was admitted to Kumamoto University Hospital for the management of unstable angina. CABG was successfully performed using bilateral internal thoracic arteries and postoperative 3D-CT demonstrated good patency of both arterial grafts. The patient experienced no significant postoperative complications, and has remained well to date (8 months postdischarge).

A Case of Primary Cardiac Lymphoma Diagnosed by Open Biopsy with Median Sternotomy / 日本心臓血管外科学会雑誌

An 60-year-old man who initially presented with ventricular tachycardia was suspected of cardiac tumor because of localised hypertrophy of the right ventricle. Although the localized region detected by an echocardiography suggested malignancy, percutaneous transcatheter myocardial biopsy failed to obtain a histological diagnosis. Six months later, a permanent pace maker was implanted due to complete AV block. Two years after the first admission, echocardiogram and computed tomography demonstrated a cardiac tumor in the right ventricle. To obtain a histological diagnosis, open biopsy was performed under median sternotomy and showed malignant lymphoma. Antemortem diagnosis of cardiac malignancy is usually very difficult. Median sternotomy is an established procedure for cardiovascular surgeons. Open biopsy can be an acceptable technique to obtain histological diagnosis of the neoplastic region in terms of safety and simplicity, and has good sampling accuracy compared with other diagnostic modalities. We recommend early stage surgical exploration when cardiac malignancy is a diagnostic possibility.

Long Term Clinical Results in Axillofemoral Bypass for Aortoiliac Occlusive Disease, Especially in Terms of QOL / 日本心臓血管外科学会雑誌

The purpose of this study is to clarify the appropriateness of axillofemoral bypass for high-risk patients with aortoiliac occlusive disease. From February 1986 through November 1997, 50 axillofemoral bypasses were performed at our institution. The mean age of patients was 70.3± 9.6 years (range 28 to 86 years) and 90% of them had severe associated disease. Twenty-nine grafts had axillounifemoral configuration and 21 grafts had axillobifemoral configuration. The primary and secondary patency rate, during this 11-year period (mean follow-up 47.0±30.1months), were 66.4 % and 78.3% at 5 years, with no change thereafter. The mortality rate within 30days was 2%. During the follow-up period 22 died mainly due to heart disease, cerebrovascular disease or malignant tumor, and the survival rate at 5 years was 56.3%. Fontaine classification evaluation revealed that ischemic symptoms improved in 78% of 28 survivors. According to QOL study 75% of survivors were satisfied with daily life, and their performance status improved after operation. These findings indicate that axillofemoral bypass may be an appropriate procedure for high risk patients with aortoiliac occlusive disease.