ABSTRACT
A 75-year-old man was referred to our hospital with a chief complaint of sudden back pain and fever. Enhanced CT showed a Kommerell diverticulum (KD) with right aortic arch and aberrant left subclavian artery (ALSA). It also showed type B aortic dissection with a closed false lumen and the horizontal diameter of the KD was 73 mm. We decided on elective surgery because the size of the KD was so large ; he also had aortic dissection and difficulty in swallowing due to compression of the esophagus. We avoided thoracotomy because it was challenging to approach to the KD and reconstruct the ALSA in situ. There also was the risk of injury to organs around the KD especially the esophagus and trachea via thoracotomy. Therefore, we performed an elective one-stage operation comprising total arch replacement (TAR) and frozen elephant trunk (FET) through median sternotomy followed by thoracic endovascular aortic repair (TEVAR). We could perform the operation safely with a good field of view. This strategy did not need a thoracotomy or in situ reconstruction of the ALSA. The post-operative course was uneventful and he was discharged 18 days after the operation. A CT scan 6 months after the operation showed size reduction of the thrombosed KD with no residual leakage of the stent graft. This hybrid method is one effective option for a KD with right aortic arch and ALSA. We report a successful one-stage hybrid operation for KD with some literature review.
ABSTRACT
Objective : The mainstream strategy for blunt traumatic thoracic aortic injuries (BTAI) has been shifting from conventional open repair (OR) to thoracic endovascular aortic repair (TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods : We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results : Eighteen cases were identified. Of these, 7 patients (38.9%, mean age 62.0±15.2 years) were treated with OR and 11 (61.1%, mean age 61.8±21.3 years) were treated with TEVAR. There was significant reduction in the mean operative duration (OR 444±145 vs TEVAR 65±14 min ; p＜0.001), the mean intraoperative blood loss (OR 2,787±1,578 vs TEVAR 210±376 ml ; p＜0.001), the volume of blood transfusions (OR 5,042±2,219 vs TEVAR 929±751 ml ; p＜0.001), and the mean dose of heparin infusion (OR 20.3±4.1 vs TEVAR 7.9±8.5 ml ; p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0% (p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate (average follow-up period of 42.0±56.9 months). Conclusions : Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.
ABSTRACT
The patient in this case was a boy aged 2 years and 9 months. The patient was transferred to our hospital with ductal shock, and bilateral pulmonary artery banding was performed on the 9th day after the diagnosis of interruption of the aortic arch, ventricular septal defect, subaortic stenosis, and bicuspid aortic valve. Left ventricular outflow tract stenosis due to aortic annulus diameter and subaortic stenosis after repair was suspected. Damus-Kaye-Stansel (DKS) anastomosis, extended aortic arch anastomosis, and a right modified Blalock-Taussig operation were performed. Preoperative examination of the intracardiac repair showed growth of the aortic annulus and confirmed that biventricular repair was possible after DKS take-down. The patient's native aortic and pulmonary valves were preserved, and an intracardiac repair was performed without using an extracardiac conduit. The postoperative course was uneventful, and the patient is currently in a good condition at the age of 6 years. Three and a half years after surgical intervention, echocardiography and cardiac catheterization showed improvement of subaortic stenosis and enlargement of the aortic annulus. Our findings indicate that the most appropriate surgical procedure can be selected by detailed examination of the preoperative condition at each stage of the staged operation.
ABSTRACT
Although aortic annular abscess and rupture of the sinus of Valsalva are known as complications of infective endocarditis, few cases in children have been reported. We report a surgical case of a 6-year-old girl with active infective endocarditis complicated with an annular abscess and pseudoaneurysm of the sinus of Valsalva. The patient presented progressive symptoms of heart failure and a subsequent echocardiogram demonstrated severe aortic regurgitation. A computed tomography indicated pseudoaneurysm of sinus of Valsalva and an emergency operation was performed. At operation, a bicuspid aortic valve with vegetation was noted. The annular abscess caused a large tissue defect of the left coronary sinus of Valsalva and formed a pseudoaneurysm. The infected lesion was resected completely. The defective aortic annulus and sinus of Valsalva were repaired with a bovine pericardial patch and aortic valve was replaced with a mechanical valve. The postoperative course was uneventful and the patient was discharged after adequate antibiotic treatment.
ABSTRACT
Papillary muscle rupture is one of the common complications of acute myocardial infarction. We report a case of 77-years-old man with an acute posterior papillary muscle rupture without obvious coronary artery disease. The patient presented with cardiogenic shock and pulmonary edema. Emergency coronary angiogram showed no obstruction in coronary arteries. An echocardiogram and right heart catheterization data suggested acute mitral regurgitation caused by ruptured posterior papillary muscle. Percutaneous cardiopulmonary support was induced because of his unstable hemodynamics, and then emergency mitral valve replacement was performed. Intraoperative findings suggested some ischemic changes in the posterior papillary muscle. Pathologically, both old and new ischemic lesion presented in the same papillary muscle. Moreover, severe thickening of a small vessel wall was noted. This case presented one of the possible mechanisms of so-called idiopathic papillary muscle rupture.
ABSTRACT
A 39-year-old woman, who had undergone aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis 16 years previously, was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. An emergency operation was undertaken with the patient in a state of shock due to sudden cardiac arrest. The ascending aorta was cross clamped, and cardiac arrest was induced, and aortotomy was done. One of the leaflets of the CEP was entirely collapsed and dislocated to the LV side, which caused acute aortic regurgitation. Although there was no evidence of endocarditis, slight calcification and small perforation of the leaflet of the valve was observed. Aortic valve replacement was performed with a mechanical heart valve but it was impossible to wean from ECC, and therefore we additionally performed mitral valve annuloplasty with a prosthetic ring for moderate mitral regurgitation. After 4 h cardiopulmonary assistance, ECC was successfully withdrawn. She was discharged in a good condition an post operative day 29th.
ABSTRACT
A 50-year-old man with Marfan syndrome, was given a diagnosis of pseudoaneurysm in an anastomotic site of the left coronary artery after Bentall operation, with severe calcification. He was successfully treated with reanastomosis of a new graft to the left main trunk by the removal of a calcified intima. Coronary artery bypass grafting was not possible because his coronary arteries were covered with thickened fatty tissue due to a previous omental flap procedure for mediastinitis, and therefore we chose left main trunk coronary angioplasty. The whole calcified intima was excluded with a dissector and resected at both ostias of the left descending artery and left circumflex artery. An 8-mm woven Dacron graft was anastomosed at the left main trunk by large stitches of adhesive tissue around the adventitia, to the inside of the lumen of the left main trunk. The patency of the left main trunk was confirmed by CT and he was discharged in a good condition. Close observation is needed for long-term morbidity.
ABSTRACT
Tachycardia caused by increased sympathetic nerve activity after cardiovascular surgery can induce an increase in myocardial oxygen consumption and myocardial ischemia. β-Blockers are expected to reduce myocardial oxygen consumption, but traditional β-blockers are long acting so it is difficult to use after cardiovascular surgery. From January 2007 to September 2007, 24 out of 60 patients who underwent cardiovascular surgery were administered landiolol. The average heart rate before landiolol infusion was 99.5±16.5 bpm and decreased to 89.5±10.7 bpm after landiolol infusion (<i>p</i>=0.0008). Average systolic blood pressure before and after landiolol infusion was 109±16 mmHg and 103±13 mmHg, respectively (<i>p</i>=0.15). Average cardiac index (14 patients) before and after landiolol infusion was 3.29±0.83 <i>l</i>/min/m<sup>2</sup>and 3.26±0.9 <i>l</i>/min/m<sup>2</sup>, respectively (<i>p</i>=0.75). Four patients (17%) had atrial fibrillation during these hospital stay, whereas 20 patients out of 50 patients (40%) who underwent cardiovascular surgery before landiolol was used (from June 2006 to January 2007) had atrial fibrillation (<i>p</i>=0.045). Landiolol can be effective and used safely after cardiovascular surgery.
ABSTRACT
Tachycardia caused by increased sympathetic nerve activity after cardiovascular surgery can induce an increase in myocardial oxygen consumption and myocardial ischemia. β-Blockers are expected to reduce myocardial oxygen consumption, but traditional β-blockers are long acting so it is difficult to use after cardiovascular surgery. From January 2007 to September 2007, 24 out of 60 patients who underwent cardiovascular surgery were administered landiolol. The average heart rate before landiolol infusion was 99.5±16.5 bpm and decreased to 89.5±10.7 bpm after landiolol infusion (<i>p</i>=0.0008). Average systolic blood pressure before and after landiolol infusion was 109±16 mmHg and 103±13 mmHg, respectively (<i>p</i>=0.15). Average cardiac index (14 patients) before and after landiolol infusion was 3.29±0.83 <i>l</i>/min/m<sup>2</sup>and 3.26±0.9 <i>l</i>/min/m<sup>2</sup>, respectively (<i>p</i>=0.75). Four patients (17%) had atrial fibrillation during these hospital stay, whereas 20 patients out of 50 patients (40%) who underwent cardiovascular surgery before landiolol was used (from June 2006 to January 2007) had atrial fibrillation (<i>p</i>=0.045). Landiolol can be effective and used safely after cardiovascular surgery.
ABSTRACT
The Fontan type operation is currently considered to be a safe procedure. However, in some patients excluded from the indication for the Fontan type operation is contraindicated. A 12-year-old girl given a diagnosis of pulmonary atresia with intact ventricular septum was considered a high risk and was excluded form the indications of the Fontan procedure. She underwent balloon angioplasty for aortic stenosis (valvular) at the age of 2, and bidirectional Glenn anastomosis and aortic valve plasty at the age of 5. At the age of 7, she underwent cardiac catheterization. Although the Fontan procedure was contraindicated, her symptoms gradually progressed year by year, and desaturation caused a decrease in her exercise tolerance. At age 12, she underwent coil embolization of aortopulmonary collaterals and a fenestrated Fontan procedure. In order to keep the procedure as minimally invasive as possible, we performed intraoperative stenting of the peripheral pulmonary stenosis, and all manipulation of fenestrated extracardiac conduit Fontan procedures were performed in the beating heart with cardiopulmonary bypass. The postoperative course was uneventful. The oxygen saturation increased to 95%, and her exercise tolerance dramatically improved. Here we report some special techniques that hybrid operation and satisfactory results.
ABSTRACT
Infracardiac type total anomalous pulmonary venous connection (TAPVC) was diagnosed in a 1-day-old boy. We performed emergency total correction on day 1 and found 2 vertical veins draining to the infracardiac level separately. Each vertical vein was rerouted to the left atrium. On the first postoperative day, an extracorporeal membrane oxygenation was required because of respiratory failure. He died due to cerebral hemorrhage on the 5th day after the operation. Macroscopic findings showed the right sided vertical vein draining to the IVC, and the left sided one to the confluence of the hepatic vein and ductus venosus. Microscopic findings of the lung revealed markedly dilated lymphatics which was suspected as the cause of respiratory failure. Although cases with 2 separate vertical veins are very rare, the precise anatomy of PV return has to be checked intraoperatively when the preoperative identification has not been established.
ABSTRACT
We treated two cases of Stanford type A acute dissecting aortic aneurysm with the adventitial inversion technique. Both case 1) a 65-year-old woman and 2) a 74-year-old woman underwent emergency operation. After cardiopulmonary bypass was established as usual, the diseased aorta was resected, and the intima was trimmed about 10mm shorter than the transected adventitial line in both proximal and distal ends. After GRF glue was employed, the adventitia was inverted inward over the false-lumen, and then tacked with horizontal continuous mattress sutures using 5-0 polypropylene. The graft was then anastomosed with continuous sutures using 3-0 polypropylene. No bleeding occurred from the anastomosis site in both cases. This method was completed without the use of artificial reinforcement, nevertheless patent anastomosis was possible. This simple method was easily performed and proved to be safe and useful.