A Case of Paraplegia after Total Arch Replacement with Frozen Elephant Trunk for Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

The frozen elephant trunk technique (FET) for the treatment of acute aortic dissection is associated with more favorable remodeling in the descending aorta compared to those patients without FET, but it may also be associated with postoperative spinal cord injury (SCI) and actually,some postoperative SCI cases after FET are reported. Several risk factors for SCI are known and one of them is due to the occlusion of intercostal arteries from false lumen. A 71-year-old woman underwent total arch replacement with FET, but after surgery, she noticed decreased movement in both lower extremities and was suspected of postoperative paraplegia. She went through cerebrospinal fluid drainage but didn't get better at all. According to the preoperative contrast computed tomography images, seven out of ten intercostal arteries were originating from the false lumen and six of them were occluded after surgery. When most of intercostal arteries are originating from the false lumen and there is no entry inside the descending and abdominal aorta, the intercostal arteries may be occluded due to thrombosis of the false lumen and it may cause spinal cord ischemia after surgery.

A Case of Anomalous Aortic Origin of the Right Coronary Artery Treated by Direct Coronary Reimplantation / 日本心臓血管外科学会雑誌

Anomalous aortic origin of a coronary artery is a rare congenital anomaly that can cause myocardial ischemia and ventricular arrhythmia. This disease initially manifests as cardiac arrest in half of patients. The indications and surgical strategy remain unclear, especially in patients who are asymptomatic and have poor ischemic findings. We report a surgical strategy to treat anomalous aortic origin of the right coronary artery. A 47-year-old man with a chief complaint of chest tightness was diagnosed with anomalous aortic origin of the right coronary artery, which branches from the left sinus of Valsalva and runs an inter-arterial course. Although no objective myocardial ischemia was identified with blood tests, electrocardiography, or cardiac catheterization, we suspected that the cause of the thoracic symptoms was sharp branching of the right coronary artery, which was compressed between the ascending aorta and the pulmonary artery. To reduce the risk of sudden death in the future, we performed reimplantation of the right coronary artery. Good imaging results were obtained, and the patient is currently undergoing outpatient follow up and has not experienced recurrence of chest symptoms. We conclude that our surgical strategy to treat anomalous aortic origin of a coronary artery may be useful in the clinic.

A Surgical Case of Midventricular Hypertrophic Obstructive Cardiomyopathy with Apical Aneurysm / 日本心臓血管外科学会雑誌

Hypertrophic cardiomyopathy with apical aneurysm is known to have high risk of a sudden death due to ventricular arrhythmias or thromboembolisms. We report a surgical case of surgical case of this disease. A 67-year-old man was found to have abnormality in an electrocardiogram during his checkup, and subsequent careful examinations revealed his disease. He had no symptoms and the pressure gradient at the obstruction was about 30 mmHg, but there was thrombus in the apical aneurysm. After anticoagulant therapy, the thrombus dissolved. We scheduled an operation on him because he was judged to have high risk of a sudden death. In the operation, excision of the apical aneurysm, and hypertrophic midventricular myocardium were performed, concomitant with cryoablation to the border between the aneurysm and normal myocardium. Although complete atrioventricular block occurred postoperatively and he needed permanent pacemaker implantation, he was discharged from the hospital 21 days postoperatively without any other complications. He is doing well at two years and six months, postoperatively.

Surgical Strategy for Mitral Valve Infective Endocarditis with Concomitant Cerebral Hemorrhage and Disseminated Intravascular Coagulation Syndrome : Decompressive Craniotomy before Open-Heart Surgery / 日本心臓血管外科学会雑誌

A 51-year-old woman presented with a high fever and weakness and was diagnosed with mitral valve infective endocarditis. Medical treatment was unsuccessful, and the patient developed disseminated intravascular coagulation syndrome, multiple cerebral infarctions, and massive cerebral hemorrhage. She was transferred to our hospital for surgical treatment. On admission, she had motor aphasia and right-sided hemiplegia. Echocardiography showed mild mitral regurgitation with a huge mobile vegetation measuring greater than 20 mm on the anterior leaflets. Head CT showed a huge cerebral hemorrhage in the left frontal lobe. Chest radiography revealed severe pulmonary congestion, and laboratory data showed disseminated intravascular coagulation syndrome. Despite medical treatment, the pulmonary congestion worsened. There were concerns that a fatal cerebral infarction would develop, and so urgent open-heart surgery was performed. On the day after the cerebral hemorrhage had occurred, hematoma removal and decompressive craniotomy were performed to reduce the risks associated with cardiopulmonary bypass. Four days after the craniotomy, mitral valve plasty was performed following the complete excision of the infected tissue. Heparin was administered at our normal dosage as an anticoagulant during cardiopulmonary bypass. Postoperative head CT showed no aggravation of the preoperative cerebral lesion. The patient still had symptomatic epilepsy and difficulty performing exact movements with her right hand, but she was able to walk unaided after 1 year of rehabilitation. Generally, early surgery for infective endocarditis is not recommended if the patient has concomitant cerebral hemorrhage ; our strategy may be the safest option for patients in such a serious condition.

Resection of Myxoma in the Acute Phase of Hemorrhagic Cerebral Infarction / 日本心臓血管外科学会雑誌

Early surgical resection for cardiac myxoma is necessary because it may frequently cause cerebral infarction. However the optimal surgical timing for the disease is controversial because the acute phase of infarction may induce intracranial hemorrhage. An 82-year-old woman referred to our hospital because of unconsciousness and right hemiparesis. MRI showed infarction in the left middle cerebral artery area and UCG revealed a left atrial mass. The fourth day after the onset, brain CT showed hemorrhagic infarction and MRI showed new infarction. There was no enlargement of the hemorrhagic focus on brain CT and the patient underwent surgery on the fifth day after the onset. The postoperative course was uneventful. Despite the existence of hemorrhagic infarction, open heart surgery may save patients with cerebrovascular event.

A Case of Constrictive Pericarditis after Open-Heart Surgery Effectively Treated with Pericardiectomy / 日本心臓血管外科学会雑誌

Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5 <i>l</i>/min/m² to 2.7 <i>l</i>/min/m², and central venous pressure improved from 17 to 10 mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.

Surgical Treatment for a Trauma-Caused Cardiac Rupture / 日本心臓血管外科学会雑誌

The survival rate of patients with cardiac rupture due to a blunt trauma is low, therefore it is necessary to have a well-defined diagnostic and treatment plan in order to improve the survival rate. In 8 such patients transthoracic echocardiograms at the time of arrival at our hospital showed pericardial effusion with cardiac tamponade in all patients. The mean time between suffering the injury and arriving at the hospital was 186±185min, and the mean time between arrival and being brought to the operating room was 82±49min. Preoperative pericardial drainage was performed in 2 patients, and percutaneous cardiopulmonary support system was used in 2 patients. The rupture site was in the right atrium in 3 patients, the right atrium-inferior vena cava in 1 patient, the right ventricle in 2 patients, the left atrium in 1 patient, and the left ventricle in 1 patient. Extracorporeal circulation was used in 4 patients, and the injured site was repaired. We were thus able to save the lives of 6 of the 8 patients (survival rate 75%). Transthoracic echocardiography was easy to perform and effective for making an accurate diagnosis. Many such patients tend to have multiple traumas, but, if the patient is in a state of shock due to cardiac tamponade, the patient should be moved immediately to the operating room. It is important to provide circulatory maintenance until surgery, and pericardial drainage and PCPS are also effective additional treatment modalities.

Successful Surgical Correction for an Abdominal Aortic Aneurysm in Two Elderly Patients Aged over 90 / 日本心臓血管外科学会雑誌

Surgical treatment of abdominal aortic aneurysms in elderly patients aged over 90 is rare, and the surgical indications in such patients is controversial. Two cases of abdominal aortic aneurysm successfully treated surgically are reported. The first case was a 92-year-old woman, who manifested a severe abdominal pain without hypotension. An impending rupture of an abdominal aortic aneurysm was suggested on enhanced CT scan, and emergency surgery was indicated. The aneurysm was replaced with a woven Dacron Y-graft. Postoperatively, the patient's social activity returned to the preoperative level. The second case was a 91-year-old man, in whom an increasing abdominal aortic aneurysm had been pointed out on UCG and enhanced CT scan. Because he was socially very active for his age, elective surgery was indicated. The aneurysm was resected and replaced with a woven Dacron I-graft. Postoperatively, the patient overcame a respiratory complication and was eventually discharged without any physical complication. Although he was able to climb mountains before the surgery, he lost some physical activity after the surgery. Because of the potential decrease in physical strength especially in very elderly patients, the general risk evaluation did not always correspond to a precise evaluation and prediction of postoperative activity. It is therefore necessary to be flexible in deciding on the surgical indications in each case.