Concomitant Replacement of Aortic Valve, Ascending Aorta and Pulmonary Valve 45 Years after Repair of Tetralogy of Fallot / 日本心臓血管外科学会雑誌

We present a 70-year-old woman who underwent a classic Blalock-Taussig shunt for tetralogy of Fallot (TOF), followed by intra-cardiac repair at the age of 25 years. She developed heart failure due to aortic regurgitation with aortic root dilatation and pulmonary regurgitation 45 years after the surgery. She was successfully treated with concomitant biventricular outflow tract reconstruction (aortic valve, ascending aorta, and pulmonary valve replacement). The treatment strategy for aortic regurgitation with aortic root dilatation after TOF repair is unclear. With a transient increase in the number of elderly patients who have undergone the classic Blalock-Taussig shunt as palliative surgery, the number of complex cases of both right and left ventricular outlet tract involvement will also increase. With patients' advanced age and situation of complex reoperation taken into consideration, aortic valve and ascending aorta replacement may be useful options for cases of aortic regurgitation and aortic root dilatation.

An Infant Case of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Successfully Treated with Modified Spiral Cuff Technique / 日本心臓血管外科学会雑誌

The patient was a six-month-old girl with an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). She had fever and visited a family physician at 5 months of age. Because of poor oxygenation, she was referred to our pediatric department and intubated soon after hospitalization. Echocardiography showed that the orifice of left coronary artery was just above pulmonary commissure, the left ventricular ejection fraction was 9%, and the level of mitral regurgitation was moderate. Right coronary angiography showed that the left coronary artery contrasted against the collateral arteries. The left coronary artery originated from the left side of the pulmonary trunk. After recovery of the general condition with medical therapy, the patient underwent coronary artery reconstruction by the modified spiral cuff technique on the 21st day of hospitalization. The temporary detachment of pulmonary valve and its commissure for making a margin around the left coronary artery enabled us to make the spiral cuff in almost the usual manner. She was moved to the intensive care unit with the support of extracorporeal membrane oxygenation (VA-ECMO) and was successfully weaned off the VA-ECMO 5 days after the surgery. The postoperative course was good, and she was discharged from our hospital 3 months after the surgery. The echocardiogram one year after the surgery showed a left ventricular ejection fraction of 30%, mild mitral regurgitation, and mild pulmonary regurgitation. Our experience indicates that the spiral cuff technique is a useful coronary reconstruction method for the treatment of ALCAPA, especially in cases presenting a considerable distance between the origin of the left coronary artery and the transplantation site. There are few reports regarding the surgical treatment of infantile ALCAPA showing reduced left ventricular function. Coronary artery reconstruction using the spiral cuff method and planned VA-ECMO are useful surgical procedures in such cases. Our experience also suggests that the establishment of a treatment strategy including mechanical support is essential to improve the results in severe ALCAPA cases.

Open Repair without Esophagectomy for an Aortoesophageal Fistula after Thoracic Stent Grafting / 日本心臓血管外科学会雑誌

An aortoesophageal fistula is a critical condition with high operative mortality. A case of aortoesophageal fistula following thoracic endovascular aneurysm repair is reported. The patient was a 72-year-old man complaining of dysphagia who underwent stent grafting for a saccular aneurysm of the descending aorta that was compressing the esophagus four months earlier. Endoscopic examination showed perforation of the aneurysm into the esophagus with severe stenosis. The aneurysmal sac was filled with thrombus. Aortography demonstrated a type I endoleak from the lesser curvature of the aortic arch, draining into the aneurysmal sac. The patient was afebrile with moderate elevation of C-reactive protein, and the white blood cell count was normal. The patient underwent closure of the aneurysmal entry with healthy aortic wall and replacement of the descending aortic aneurysm with a prosthetic graft. The graft was isolated from the fistula by an omental flap. The patient's postoperative course was uneventful. Computed tomography performed 4 years after the surgery showed shrinkage of the aneurysmal sac. The patient has had a healthy life for 9 years since the operation.

A Case in Which Inhaled Nitric Oxide Was Effective for Managing Pulmonary Hypertension after Mitral Valve Replacement / 日本心臓血管外科学会雑誌

Pulmonary hypertension persisted in a 57-year-old man after mitral and tricuspid valve replacement to treat mitral and tricuspid regurgitation. Heart failure gradually worsened after surgery. Pulmonary hypertension was initially considered as the major reason for the heart failure, and inhaled nitric oxide was administered. Thereafter, the heart failure improved and mechanical circulatory assist could have been avoided. We believe that inhaled nitric oxide is a less invasive and effective method for improving pulmonary hypertension and hemodynamics after mitral valve replacement.

Simultaneous Repair of Pulmonary Artery Sling and Tracheal Stenosis in Neonate / 日本心臓血管外科学会雑誌

A 17-days-old-girl with pulmonary artery (PA) sling, patent ductus arteriosus (PDA), and persistent left superior vena cava was admitted to our hospital. Despite good respiratory status just after birth, the respiratory status gradually worsened, and tracheal intubation was performed on 13th day after birth. Emergency division of the PDA was conducted on day 16. Although preoperative computed-tomography did not demonstrate tracheal stenosis, bronchoscopy after tracheal intubation revealed progression of tracheal stenosis with difficulty for stable anesthetic management. Therefore, operation was postponed to re-evaluate tracheal stenosis. Bronchoscopy and computed-tomography revealed the worsening of tracheal stenosis. Eventually, we performed total correction of the PA sling and tracheal stenosis on day 17. Cardiopulmonary bypass was established after median sternotomy. After transection of the PDA, the left PA originating from the right PA was also transected, and transplanted to the main PA. Then, sliding tracheoplasty was performed following the division of the tracheal stenotic region. Her respiratory condition improved after operation, and postoperative computed-tomography showed successful correction of tracheal stenosis. Although few such cases were reported for neonatal PA sling requiring concomitant tracheoplasty, this case suggests that total correction of PA sling and tracheal stenosis is feasible and useful surgical procedure for such cases.

Concomitant Valve Surgery and Long Distal Bypass for Severe Mitral Regurgitation and Critical Limb Ischemia / 日本心臓血管外科学会雑誌

<p>A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function (ejection fraction : 27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.</p>

Fontan Procedure and Pectus Excavatum Repair—Simultaneous Surgery— / 日本心臓血管外科学会雑誌

<p>A five-year-old boy with a univentricular heart, inferior vena cava interruption, and azygos connection was admitted to our hospital to undergo a staged Fontan-type procedure. Pectus excavatum had developed after he underwent total cavopulmonary shunt at the age of three years. Computed tomography revealed that the hepatic vein was just behind the recessed sternum. We performed simultaneous Nuss and Fontan-type procedures because we were afraid of the compression of the Fontan pathway from the hepatic vein to the pulmonary artery by the recessed sternum. A cardiopulmonary bypass was established and the hepatic vein and pulmonary artery were bypassed with a 16-mm expanded polytetrafluoroethylene graft. After removing the cardiopulmonary bypass, the Nuss procedure was performed. Although the bilateral thoracic cavities were diffusely and densely adhered, adhesiotomy was safely performed under direct visualization. The postoperative course was uneventful. Postoperative computed tomography showed that the pectus excavatum was well repaired and the Fontan pathway was not compressed by the sternum. Although there are few reports of Fontan-type and Nuss procedures being simultaneously performed, this method is useful for securing the space of the Fontan pathway and for preserving good Fontan circulation in the long term.</p>

The Efficacy of Conventional Aortic Valve Replacement for Severe Aortic Valve Stenosis Divided by Risk Classification Using the Japanese Scoring System / 日本心臓血管外科学会雑誌

<b>Objective</b> : Transarterial or transapical aortic valve replacement (TAVR) procedures have been performed for high-risk patients with severe aortic valve stenosis (AS) in western countries. A high-risk patient is defined as having an STS score greater than 10%. In Japan, aortic valve replacement (AVR) with cardiopulmonary bypass (CPB) is standard care for AS, even if the patient is at high risk of developing complications. We calculated an expected operative risk of patients using a JAPAN score established by Japanese Adult Cardiovascular Surgery Database (JACVSD). <b>Patients and Methods</b> : Patients were divided into three groups : score less than 5%, low risk (LR) ; score 5-10%, moderate risk (MR) ; score more than 10%, high risk (HR). We also evaluated the efficacy of conventional AVR in each group. Between January 2002 and May 2011, we performed conventional AVR in our hospital and 116 patients who underwent AVR for symptomatic AS were enrolled in this study. <b>Results</b> : There were 79 patients in the LR group, 30 patients in the MR group and 7 patients in the HR group. The mean score was 2.6±1.1% in the LR group, 6.8±1.4% in the MR group and 23.3±16.8% in the HR group respectively. The mean follow-up period was 7.6±0.3 years. Preoperative co-morbidity was not statistically significant among three groups, however more octogenarians were found in the HR group. The aortic valve area and left ventricular ejection fraction (LVEF) were significantly smaller in the HR group. There were 4 cancer patients. The HR group had significantly longer operation and CPB times than the LR group. The operative mortality in all cases was 1.6%. Overall survival at 5 years was 78%. Actual survival at 5 years was 77% in the LR group, 82% in the MR group and 71% in the HR group. The major adverse cardiac and cerebrovascular event (MACCE)-free ratio at 5 years was 85%. Absence of death caused by MACCE at 5 years was 93%. All cancer patients died after AVR due to advancement in cancer. <b>Conclusion</b> : The results of conventional AVR with CPB were satisfactory in each group. Cancer patients may be good candidates for TAVR in the future.

Aortic Dissection Caused by the Right Axillary Artery Perfusion / 日本心臓血管外科学会雑誌

Aortic dissection during cardiac operation is a rare but serious complication. Early detection and adequate repair is essential in this situation. A 69-year-old man in whom an aortic valve sparing operation for aortic root dilatation with aortic regurgitation had been begun, had an intraoperative aortic dissection 10min after the start of right axillary artery perfusion. Intraoperative transesophageal echocardiography and direct epi-aortic echo revealed acute aortic dissection extending from the aortic root to at least the descending aorta. The dissection was successfully repaired by a Bentall operation and hemiarch replacement using hypothermic circulatory arrest, selective cerebral perfusion, and antegrade perfusion from an anastomosed graft.

Mycotic Inferior Mesenteric Aneurysm Penetrating to Duodenum: Observation of the Formative Course / 日本心臓血管外科学会雑誌

A 64-year-old woman who had a fever and low back pain was referred to our institution. Abdominal computed tomography revealed a low density area around the aorta and inferior mesenteric artery and liver abscess. Under the diagnosis of mycotic abdominal aneurysm, intravenous administration of antibiotics was started and her symptoms improved. On the 12th day after admission, the patient developed hematemesis and an emergency CT scan revealed enlargement of the low density area around the aorta and dilatation of the inferior mesenteric artery diameter to 16mm. Urgent operation was performed under the diagnosis of impending rupture of the mycotic aneurysm. Necrotic tissue and hematoma was recognized outside the aorta, and this mass firmly adhered to the duodenum. Communication between the abdominal aorta and the duodenum through the inferior mesenteric artery was confirmed. The infected aneurysmal area of the aorta was almost completely resected by closing the infra-renal aorta and terminal aorta above the bifurcation and a left axillo-femoral bypass was established. The culture of the necrotic tissue revealed <i>Klebsiella pneumoniae</i>. Antimicrobial therapy was continued and the patient was discharged from the hospital on postoperative day 46. Because the mortality rate of mycotic aneurysm penetrating to the duodenum is high, early diagnosis and treatment is important. We present a successfully treated case of mycotic aneurysm in which the formative course was observed from an early stage of infection. We observed the process of mycotic aneurysm formation and aorto-duodenal fistula generation despite antibiotic therapy. Close observation of periaortic inflammation and early surgical intervention is necessary in such patients.

Two Cases of Stent-Grafting for Ruptured Aneurysms / 日本心臓血管外科学会雑誌

In cases of stent-grafting for ruptured aneurysm, endoleak is a serious problem. We report 2 cases of ruptured aneurysms that were treated with endovascular stent-graft placement. Case 1: A 79-year-old woman had a ruptured thoracic aortic aneurysm that was treated with endovascular stent-grafting from the distal arch to the descending aorta. Although her infra-operative course was uneventful, she died suddenly the day after operation. Autopsy revealed re-rupture of the aneurysm due to endoleak from the proximal site. Case 2: An 84-year-old woman was treated with endovascular stent-grafting for ruptured abdominal aortic aneurysm. The stent-graft was inserted from the infra-renal abdominal aorta to the right common iliac artery with femoro-femoral crossover bypass placement. There was evidence of type II endoleak that occurred via the left internal iliac artery (IIA) and inferior mesenteric artery (IMA) 16 days after surgery. A CT scan performed 6 months after surgery revealed an increase in aneurysm size and persistent type II endoleak. Both embolization of the aneurysmal sac through the IMA and surgical ligation of the IMA failed, and endoleak from the IMA persisted. Re-rupture of the aneurysm occurred 10 months after initial surgery and emergency open surgery was performed. In stent-grafting for ruptured aneurysms, only the thrombus outside the graft resists the pressure caused by the endoleak. We conclude that endoleak after stent-grafting for ruptured aneurysm should be treated completely as soon as possible because of the risk of re-rupture.

Surgical Treatment of Patent Ductus Arteriosus and Aortic Stenosis in a Patient with a Porcelain Aorta / 日本心臓血管外科学会雑誌

This paper reports on a case in which a heavily-calcified so-called “porcelain aorta” (including the ductus arteriosus) was observed, together with a patent ductus arteriosus and aortic stenosis associated with a bicuspid aortic valve. A 76-year-old man had been referred to our hospital on a diagnosis of aortic stenosis. Since angiography revealed slight contrast in an area on the right side of the heart, echocardiography was performed and revealed patent ductus arteriosus. Severe circumferential calcification of the ascending aorta and aortic arch was observed on CT scans. Almost no calcification was observed in other areas. Aortic valve replacement and closure of the ductus arteriosus (transpulmonary approach) were performed by means of a balloon to temporarily occlude the aorta, as surgical clamping was impossible due to calcification. Hypothermic systemic perfusion and antegrade selective cerebral perfusion were used. The postoperative progress of the patient was good. Bicuspid aortic valve and patent ductus arteriosus are highly likely to be present in combination in cases of congenital cardiac anomaly, and it is therefore necessary to be particularly attentive when diagnosing such cases. It was considered that our patient, an adult suffering patent ductus arteriosus, was a rare case in which the calcified ductus arteriosus was observed and the calcification had spread to the ascending aorta.

Early and Mid-Term Results of Endovascular Stent-Graft Placement for the Treatment of Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

We performed endovascular stent-graft placement on 39 patients with abdominal aortic aneurysms between 1996 and March 2002-a period of approximately 5 years (first half: until the end of June 1998, second half: July 1998 onward). Three patients in the first half of the period and 8 patients in the second half were 80 years or older. Two cases of mycotic aneurysm were observed. During the second half, we encountered high-risk cases in which the patients had complications such as coronary artery disease (5 patients), COPD (1 patient) and thoracic aortic aneurysm (4 patients). Although we had to switch to surgery in 3 patients during the first half of the period, we successfully placed stent-grafts in the other 36 cases (92%). Endoleaks were observed in 6 patients, and dissection of the iliac artery was observed in 5 patients (stents had been placed in all patients). In 50% of all cases in the first half of the period and 89% of all cases in the second half, stent-graft placement was successful and no endoleak was observed. During the follow-up period, 3 cases required additional treatment, and another 4 cases required surgery. Four patients died in hospital during the first half of the period, and 3 patients died during the following 3 years. The 3-year survival rate was 82%. It was considered that stent-graft placement for abdominal aortic aneurysms is particularly effective for high-risk patients, and that the results of this type of therapy will improve in the future.

A Case of Aortocaval Fistula as a Complication of Aortoiliac Aneurysm / 日本心臓血管外科学会雑誌

A 75-year-oldm an with an aortocaval fistula as a complication of aortoiliac aneurysm visited our hospital. He complained of shortness of breath and melena. Physical examination revealed a pulsating abdominal mass with thrill and continuous murmur. Chest X ray showed cardiomegaly with pulmonary congestion. CT scan showed infrarenal aortoiliac aneurysm and echo Doppler scan revealed aortocaval communication at the inferior caval bifurcation. Aortoiliac bifurcated graft and patch reconstruction of IVC were performed. The postoperative course was uneventful, and his congestive heart failure and hepatorenal dysfunction immediately improved.

A case of aortoenteric fistula associated with behcet disease / 日本心臓血管外科学会雑誌

Aortoduodenal fistula is rare complication of nonoperative abdominal aortic aneurysm. We successfully treated a case of primary aortoenteric fistula associated with Behcet's Disease with two surgical intervention. The patient was 41 years old man. He admitted to our hospital because of severe shock due to enormous gastrointestinal hemorrhage. Emergency laparotomy revealed the inflammatory abdominalaneurysm ruptured into the duodenum. As the saccular aneurysm was densely adherent with duodenum and retoroperitoneum, graft replacement was abandoned. Primary closure of the perforated area of duodenum and the neck of aneurysm were performed. Axillofemoral bypass restored blood flow of the lower extremities. Three month after the operation, aortoduodenal fistula recurred. On the second operation, abdominal aorta was divided through retroperitoneal approach. However, primary closure of the enteric perforation with graft replacement of the aorta is considered as the first choice of the surgical treatment for aortoenteric fistula. In a case of difficult condition such as this patient with severe shock or retroperitoneal fibrosis, repair of the duodenum wall and division of the abdominal aorta with axillofemoral bypass is an alternative method of choice.