Transfusion-Free Surgery for a Jehovah's Witness Patient with Dilated Cardiomyopathy Treated with Mitral Complex Reconstruction / 日本心臓血管外科学会雑誌

A 22-year-old man with dilated cardiomyopathy (DCM), who was a practicing Jehovah's Witness, was transferred to our hospital for surgical treatment of medically uncontrollable mitral regurgitation (MR). Our original mitral complex reconstruction procedure and permanent pacemaker implantation for biventricular pacing were successfully performed without transfusion of blood products. Blood conservation strategy included: 1) preoperative treatment with erythropoietin, 2) utilization of a shortened extracorporeal circuit and assisted venous drainage system, 3) the use of ultrafiltration to save the residual autoblood in the extracorporeal circuit. The preoperative hemoglobin level was 17.1g/dl and the postoperative lowest level was 9.5g/dl. MR decreased from grade III to none, and NYHA functional class improved from class II to class I postoperatively. He was moved to a cardiology ward on the 13th postoperative day without complications. Transfusion-free surgery for DCM should be performed before DCM advances and requires left ventriculoplasty at risk for major blood loss. A careful follow-up is needed to examine the long-term results of the operative procedure during his expected long survival.

Clinical Experience with Terumo Large Diameter Graft (Triplex)-Results of a Multicenter Clinical Trial- / 日本心臓血管外科学会雑誌

We conducted a clinical study on a newly developed large diameter vascular graft (Triplex^®, Terumo Corporation, Tokyo, Japan) with a non-biodegradable material used as sealing material, to evaluate its effectiveness and safety. Triplex^® grafts were implanted in 170 patients with either aneurysmal or occlusive arterial disease in either the thoracic artery, abdominal artery or iliac arteries, between October 2001 and March 2003. The patients consisted of 141 men and 29 women with an average age of 69.0±10.0 years old (mean±SD). In 82 patients, Triplex^® was implanted for the thoracic artery area, in 88, for the abdominal artery area. The cumulative graft patency rate 12 months after implantation was 100.0% in each area, there was no any abnormality such as occlusion or rupture from the trunk of Triplex^®. The distension ratio, which is the index of the dilatation resistance, was 1.03±0.06 as a whole (<i>n</i>=139), 1.03±0.06 in the thoracic artery area (<i>n</i>=73), 1.03±0.06 in the abdominal artery area (<i>n</i>=66). In other words the dilatation of Triplex^® was hardly observed. As manipulability during the operation, the following characteristics were evaluated; anastomosis, resistance to fraying, hemorrhage, conformability with the host vessel. Triplex^® was evaluated as “good” in 75% of all items accounted for 75% or more. A transitory rise thought to be due to the surgical stress immediately after the operation because of the change of temperature and laboratory findings (CRP, WBC) between implantation and discharge was observed, but then recovered to the normal levels of each patients at discharge and the re-elevation was not recognized. In 90 patients, 277 adverse events occurred. Although in 33 adverse events in 21 patients a causal relation with Triplex^® could not be excluded, most of them were already known events as complications which could occur after operation on the aorta. Therefore, it was confirmed that Triplex^® has certain advantages: 1) good manipulability, 2) good patency and dilatation resistance, 3) no inflammatory reaction related to Triplex^®, as a graft for the aorta.

A Surgical Case of Type B Aortic Dissection with Concomitant Distal Aortic Arch Aneurysm / 日本心臓血管外科学会雑誌

A 70-year-old man was given emergency admission with severe back pain. Computer tomography revealed type-B acute aortic dissection with a distal aortic arch aneurysm which was 69mm in diameter. The dissection extended from the distal portion of the aneurysm to right external iliac artery, and the false lumen was patent. The right renal artery arose from the false lumen. He was treated conservatively according to the guidelines of AHA, and later we performed total arch replacement electively for the aortic arch aneurysm. Distal anastomosis was applied using the elephant trunk method for reconstruction of only the true lumen. Postoperative computer tomography showed the false lumen was closed in the descending thoracic aorta, but patent below the level of the celiac artery. He was discharged without any complications. Cases of acute aortic dissection coexisting with atherosclerotic thoracic aortic aneurysm are rare. However, with the increase of the elderly population, vascular diseases will become more complicated. Strategy for therapy and operation should be considered carefully especially in such cases with multiple vascular diseases.

Extended Retroperitoneal Approach for Ruptured Juxtarenal Abdominal Aortic Aneurysm in a Patient with a History of Laparotomy / 日本心臓血管外科学会雑誌

We reported a successful emergency operation for ruptured juxtarenal abdominal aortic aneurysm via an extended retroperitoneal approach. A 70-year-old man with a history of distal gastrectomy and pancreatoduodenectomy complained of epigastric pain and was transferred to our emergency room in a state of shock. Computed tomograpy demonstrated a ruptured juxtarenal abdominal aortic aneurysm and massive intraperitoneal hematoma. We performed emergency graft replacement through an extended retroperitoneal approach in order to control the aorta quickly, safely, and reliably. This approach is a useful option in the emergency treatment of ruptured juxtarenal abdominal aortic aneurysm.

A Case of Takayasu's Arteritis That Developed Impending Ruptured Subclavian Artery Aneurysm Associated with Sepsis during Steroid Therapy / 日本心臓血管外科学会雑誌

A 20-year-old woman had intermittent fever frequently since dental therapy one year previously. Two months previously Takayasu's arteritis had been diagnosed and she had been given 30mg/day prednisolone. She then developed subarachnoid hemorrhage, left arm pain/cataplexy, purpura, sight disturbance, and sepsis caused by <i>Serratia</i>. Finally she felt chest pain and a left Subclavian artery pseudoaneurysm was detected out. Therefore she was transferred to our service for emergency surgery. Preoperative angiography demonstrated post-stenosis aneurysm in the right common carotid artery, left common carotid artery aneurysm, and saccular pseudoaneurysm in the left subclavian artery that suggested impending rupture. The operation was performed through a left upper partial sternotomy extended to the left supraclavicular space. The left subclavian artery was ligated proximal to the aneurysm and distal portion was also ligated through a subclavicular approach. The postoperative course was uneventful. No ischemic sign has been seen in her left arm one year after operation and left/right brachial artery pressure index has improved to 0.80. The patient currently takes steroids and remains healthy without signs of expansion of bilateral carotid artery aneurysms.

Surgical Treatment for a Patient with Crawford Type III Thoracoabdominal Aortic Aneurysm Associated with Occlusion of the Visceral and the Iliac Arteries / 日本心臓血管外科学会雑誌

We report a case with Crawford type III thoracoabdominal aortic aneurysm associated with occlusion/stenosis of the visceral and the iliac arteries necessitating surgical repair. The patient was a 54-year-old man. His visceral arteries were obstructed except the left renal artery which was stenotic. His iliac arterial system was also completely occluded except the patent left common and internal iliac arteries. The blood flow of his visceral organs and lower extremities depended on the collateral vessels from the left internal iliac artery. We successfully performed thoracoabdominal aortic aneurysm repair concomitant with reconstruction of the visceral arteries and the femoral arteries using partial cardiopulmonary bypass between the left internal iliac artery and the left femoral vein. It is important to select appropriate adjuncts and surgical options for patients with thoracoabdominal aortic aneurysms that involve visceral/iliac arteries.

A Case Report of Delayed-Onset Lower Spinal Cord Injury after Replacement of the Aortic Arch and the Descending Thoracic Aorta Using a Stented Elephant Trunk / 日本心臓血管外科学会雑誌

Higher incidence of spinal cord injury has been reported in total aortic arch replacement using a stented elephant trunk compared with the conventional one, perhaps due to embolism of atheromatous plaque to the spinal cord arteries. We report a case with delayed-onset lower spinal cord injury after replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. A 69-year-old man who had a history of abdominal aortic aneurysm repair using a Y-graft and untreated Crawford's type II thoracoabdominal aortic aneurysm underwent replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. He developed weakness of the lower extremities 4 days after the operation. Since a preoperative computed tomography demonstrated thrombus and atheroma in the aneurysm, atheromatous plaque that can cause embolization of the spinal cord arteries was suspected to be responsible for spinal cord injury. As this technique is mostly applied to patients with severe atheromatous aortic disease, embolization of the intercostal arteries or other main branches caused by manipulation of a stent graft must be avoided.

Surgical Treatment of Active Infective Endocarditis: Determinants of Early Outcome / 日本心臓血管外科学会雑誌

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). <i>Streptococci</i> (27.5%) and <i>Staphylococci</i> (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (<i>p</i>=0.02), New York Heart Association class III or IV (<i>p</i>=0.02), a preoperatively unidentified pathogen (<i>p</i>=0.02) and concomitant operation for abscess and fistula (<i>p</i>=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (<i>p</i>=0.11). Multivariate analysis revealed that NYHA III-IV(<i>p</i>=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (<i>p</i>=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

A Case of Valve Repair in Mitral Valve Regurgitation Associated with Acromegaly and a Review of the Literature during the Last 2 Decades / 日本心臓血管外科学会雑誌

Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. A 62-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet, which was successfully repaired. At the age of 57 years, the patient was admitted due to heart failure without valvular disease. Acromegaly was diagnosed and a pituitary tumor was removed surgically. At the age of 62, a heart murmur was found, and moderate to severe MR was diagnosed. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. Histological examination showed myxomatous degeneration. The patient recovered uneventfully. During the last 2 decades, only 21 surgical cases of valvular disease associated with acromegaly were reported in the literature; mitral valve lesions in 10 patients (all with regurgitation), aortic valve lesions in 10 patients (7 with regurgitation and 3 with stenosis), and one with combined lesions of mitral and aortic valves. Since histology did not show specific changes in many reports, it is still unclear whether valve lesions are caused by a high GH hormone level. Although mitral valve replacement was recommended in the 1990s due to the fragility of valvular rings and their apparatus, mitral repair was performed in 5 recent cases and no recurrence has been reported.

Surgical Treatment of Ebstein Anomaly in Two Adult Cases: Limitations and Difficulties of Carpentier's Procedure / 日本心臓血管外科学会雑誌

In repair of the tricuspid valve (TV) due to Ebstein's anomaly, mobilization of the anterior leaflet associated with longitudinal right ventricle placation (Carpentier's procedure) has provided good results in both short- and long-term follow-up. However, if the anterior leaflet is small or severely deformed, such repair may be ineffective. We report two cases of Ebstein's anomaly (63 and 53 years old) with deformed anterior leaflets of the TV in whom Carpentier's procedure was not feasible. In one patient, the anterior leaflets were broadly plastered on the right ventricle and Carpentier's procedure was tried. However, the repair was converted to valve replacement because of significant residual regurgitation. The other patient had a cleft in the anterior leaflet, therefore Carpentier's procedure was not suitable. The repair restructured the valve mechanism below the true annulus by using the most mobile leaflets for valve closure (modified Hetzer's procedure). This method of repair could be an alternative method to repair of the TV in Ebstein's anomaly, particularly when the anterior leaflet is deformed.

A Case of Bilateral Ureteral Stenosis due to Inflammatory Common Iliac Artery Aneurysms / 日本心臓血管外科学会雑誌

A 71-year-old man was admitted complaining of abdominal pain. Contrast enhanced CT scan showed bilateral inflammatory common iliac artery aneurysms and encasement of bilateral ureters with perianeurysmal fibrosis. Drip infusion pyelography (DIP) showed bilateral hydronephrosis. After insertion of ureteral stents, Y-graft replacement and bilateral ureterolysis were performed successfully in spite of adhesion of the ureters to the aneurysmal wall. Postoperative DIP showed good passage in ureters and improvement of hydronephrosis. We would like to emphasize the usefulness of preoperative ureteral stenting for identification and mobilization of ureters.

A Case of Mitral Valve Replacemernt in a Patient with Severe Mechanical Hemolytic Anemia after Mitral Valve Repair / 日本心臓血管外科学会雑誌

A 60-year-old man, who had undergone mitral valve repair with quadrangular resection of the posterior mitral leaflet and ring annuloplasty with a Cosgrove-Edwards ring, developed severe mechanical hemolytic anemia. Doppler echocardiography showed only mild residual mitral regurgitation, but turbulent jet was directed toward the annuloplasty ring. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent replacement of the mitral valve with a St. Jude Medical valve. Inspection of the annuloplasty ring at operation showed no evidence of dehiscence, but the area of the annuloplasty ring adjacent to the posteromedial commissure showed no endothelization. After the reoperation, the hemolysis and general condition immediately improved. This experience made us realize the possibility that a high-velocity regurgitant jet toward the cloth-covered annuloplasty ring, even if it mild, can cause severe hemolysis.

A Case of Bypass Grafting for Angina Pectoris with Anomalous Origin of the Left Anterior Descending Artery from the Right Coronary Artery / 日本心臓血管外科学会雑誌

A 55-year-old man was admitted to our hospital with angina pectoris. Coronary angiography revealed that the left anterior descending artery (LAD) originated from the proximal right coronary artery (RCA) which arose from the right coronary sinus of Valsalva, while the circumflex artery (CX) arose from the left coronary sinus of Valsalva. Multiple coronary lesions included total obstruction at the proximal RCA after branching the LAD, 75% stenosis at the origin of the LAD, and 90% stenosis at the proximal CX. These lesions were revascularized with the left interthoracic artery to the LAD, the radial artery to the RCA, and a couple of saphenous vein grafts to the CX. Postoperative angiography confirmed patency of all grafts. Anomalous coronary artery is found to be 0.62-0.83% by angiography. A rare anomalous coronary artery is documented in this article, which has been reported to be 4.4% of all anomalous coronary arteries.

Replacement of the Ascending Aorta and the Transverse Aortic Arch for Chronic DeBakey Type I Dissecting Aneurysm in a Patient with Aberrant Right Subclavian Artery / 日本心臓血管外科学会雑誌

We report a case of chronic DeBakey type I dissecting aneurysm with an aberrant right subclavian artery, in which replacement of the ascending aorta and the transverse aortic arch was performed under selective cerebral perfusion, resulting in complete obliteration of the false channel in the descending thoracic aorta. A 57-year-old female was admitted to our service complaining of chest and back pain. An aberrant right subclavian artery that originated from the descending thoracic aorta was identified. During operation, the dissected aortic wall of the aortic arch and the proximal descending thoracic aorta that involved more than half of its circumference was resected, the dissected intima was reapproximated at the distal stump, and the beveled distal end of the tubular ascending aortic prosthesis was secured to the cut edge. The postoperative course was uneventful, and she is leading a normal life now four years after surgery. It is rare to reconstruct the aortic arch for aortic dissection that occurred in a patient with aberrant right subclavian artery, and the technical details were reported.

Giant Post Stenotic Dilatation Associated with Aortic Valve Stenosis. A Case Report of Aortic Valve Replacement and Ascending Aorta Graft Replacement / 日本心臓血管外科学会雑誌

A rare case of ascending aortic aneurysm due to post stenotic dilatation associated with aortic valve stenosis in a 67-year-old man was treated surgically. Aortic valve stenosis with a systolic pressure gradient of 87mmHg was recognized. Thoracic aortogram and CTscan revealed dilatation of the ascending aorta which was 85mm in diameter. Because the ascending aorta was obviously dilated and its wall was thin at operation, the possibility of rupture was considered to be high. Aortic valve replacement using a 23mm SJM prosthetic valve was performed and graft replacement of the ascending aorta with a 28mm collagen-shield graft was carried out simultaneously. He was discharged in excellent condition on the 45th postoperative day. Pathological examination of the aortic wall revealed an apparently thin wall, but the three layer structure of the wall and elastic laminae were well preserved. Inflammation and atherosclerotic findings were not detected. It was concluded that post stenotic dilatation associated with aortic valve stenosis can develop aneurysm that eventually requires surgical treatment.

Thoracoabdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

We report 18 cases of thoracoabdominal aortic aneurysm repair. Most causes of the thoracoabdominal aortic aneurysm were atherosclerotic lesions (56%) or inflammatory changes (39%), such as Takayasu's aortitis and Behçet's disease. The Crawford procedure was performed in 13 patients, patch aortoplasty in 3, the Hardy procedure in 1 and extra-anatomic bypass in 1. As an adjunct, temporary bypass was employed in 8 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. A total of 39% of all patients required emergency surgery for rupture, and among inflammatory aneurysms 86% of them ruptured. The early mortality rate was 0% in non-ruptured thoracoabdominal aneurysms, 42.9% in ruptured and 16.7% overall. There were 3 severe post-operative complications including one each of paraplegia, non-occlusive intestinal ischemia and rupture. All of them turned resulted in in-hospital death and the in-hospital mortality rate was 33.3%. There was no late death among atherosclerotic thoracoabdominal aortic aneurysms. However both Behçet's disease cases required re-operation for rupture at the anastomotic site in the late postoperative period and one patient died. One Marfan's syndrome patient also died 3 years postoperatively. We conclude that the Crawford procedure with F-F bypass is an effective and safe approach to thoracoabdominal aortic aneurysm repair and yields good clinical results.

A Case of Replacement of the Ascending Aorta, Transverse Aortic Arch, Descending Aorta, and Upper Abdominal Aorta Using the "Elephant Trunk" Operation / 日本心臓血管外科学会雑誌

The“elephant trunk”operation, first described by Borst and associates, is a multistage operation for diffuse aneurysmal disease. We report a 59-year-old man complaining of hoarseness, who had a diffuse aneurysm extending from the ascending aorta to the upper abdominal aorta with occlusive disease in the neck branches. His aorta was replaced in two stages using the“elephant trunk”operation. The first stage operation, replacement of the ascending aorta and transverse aortic arch, was performed through a median sternotomy under selective cerebral perfusion. The second stage operation, replacement of the descending thoracic and upper abdominal aorta, was performed under F-F bypass. He had occlusive disease on bilateral carotid arteries with a history of brain infarction, had lost his left lower limb because of arteriosclerosis, and had undergone replacement of the infrarenal abdominal aorta because of an aneurysm. Despite a complicated preoperative general condition, the postoperative course was uneventful. The“elephant trunk” operation facilitates staged operation for diffuse aneurysmal disease as presented here, and thereby improves opeative result by reducing surgical stress.

Thoracoabdominal Aortic Repair of DeBakey Type IIIb Dissecting Aneurysms / 日本心臓血管外科学会雑誌

Nine patients with type IIIb dissecting aortic aneurysm underwent graft replacement of the thoracic and abdominal aorta between 1988 and 1992. The spiral opening method was used to expose the thoracic and abdominal aorta. Temporal bypass was employed in 2 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. The entire descending thoracic aorta and abdominal aorta was reconstructed in 6 patients and the proximal descending thoracic aorta to renal arteries in 3 patients. The Crawford graft inclusion technique was used in all cases. Three patients required emergency surgery for rupture in one and impending rupture in 2. Operative deaths occurred in 2 patients (22.2%). Morbidity included renal failure (2), bleeding requiring reoperation (2), arrythmia (1), paraplegia (1), paraparesis (1), respiratory failure (1) and ileus (1). In the past two years, we operated on 5 cases of type IIIb dissecting aneurysms and there was neither operative death nor paraplegia.

The Result Surgical Treatment of Type A Acute Aortic Dissection. Clinical Study of Graft Replacement of Ascending Aorta With Deep Hypothermic Circulatory Arrest / 日本心臓血管外科学会雑誌

Since January, 1981 to December, 1990, eight patients (one male, 7 female) of Stanford A type aortic dissection underwent surgical treatments with deep hypothermic circulatory arrest. The average was age 59.6 years (range 50 to 72 years). All of them were diagnosed with UCG and/or CT before operation. Two cases had already been in shock state due to cardiac tamponade. Three cases had aortic insufficiency and one had neurological deficit. After median sternotomy, right atrial-femoral artery bypass was established. Right atrium was incised and coronary sinus was cannulated. Then retrograde coronary infusion of cardioplegic solution was employed at a continuous flow rate of 20ml/kg/hr. The mean rectal temperature was 19.6°C and the mean circulatory arrest time was 35.5min (22-58min). Two of eight cases died, because of DIC followed by necrotizing enteritis at 28th postoperative day, and prolonged shock state before operation. The rest were all survived without any neurological deficits. There were no severe complications related to deep hypothermia. We concluded that deep hypothermic arrest is safe and simple method, allows good inspection of operative field and makes it easier to repair the dissected aorta.