Aorto-Left Atrial Fistula after Aortic Valve Replacement : a Rare Complication / 日本心臓血管外科学会雑誌

A 60-year-old man underwent aortic valve replacement for aortic valve regurgitation, tricuspid valve annuloplasty, and coronary artery bypass grafting. Postoperative echocardiography revealed shunted flow from the noncoronary sinus of Valsalva into the left atrium. The pathogenesis of this complication is considered to be uncertain ; however, it might be due to some kind of intraoperative injury. Three weeks after the initial surgery, we reoperated to repair the aorto-left atrial fistula. According to the intraoperative findings, small slits were found on the left atrial surface close to the posteromedial side of the mitral valve and the noncoronary sinus of Valsalva. The fistula was closed with transmural mattress sutures. Post-operative echocardiography showed no shunt flow. Although an aorto-left atrial fistula is a rare complication after aortic valve replacement, reoperation might be mandatory if the shunt flow is considerable. Surgeons should keep in mind the possibility of intraoperative injury to surrounding structures when performing aortic valve replacement.

A Case of Ruptured Abdominal Aortic Aneurysm Induced by a Hard Blow to the Abdomen / 日本心臓血管外科学会雑誌

A 77-year-old man was transferred to our hospital with a complaint of a sudden abdominal pain after receiving a hard blow to the abdomen. Contrast-enhanced CT revealed rupture of the abdominal aortic aneurysm with a massive retroperitoneal hematoma. Because of severe hemorrhagic shock, he underwent graft replacement with a woven bifurcated graft through a median laparotomy on an emergent basis. His postoperative course was uneventful and now he is doing well 3 years after surgery. Most blunt abdominal aortic injuries are caused by high-energy trauma, such as motor vehicle collisions and fall injuries. Although body blow is considered as a low-energy trauma, abdominal aortic injury could be caused in patients with an abdominal aortic aneurysm.

Successful Surgical Treatment of Tracheo-Innominate Artery Fistula Complicated with Tracheostomy / 日本心臓血管外科学会雑誌

Tracheo-innominate artery fistula is a rare complication after tracheostomy, but sometimes presents with fatal bleeding. A 10-year-old girl presented with massive bleeding from a tracheostomy that she underwent for prolonged respiratory failure caused by sequelae of mumps encephalitis. Tracheo-innominate artery fistula, complicated by tracheostomy was diagnosed, and she was transferred to our institution. Under general anesthesia, she underwent transection of the innominate artery to exclude the tracheo-innominate artery fistula via median sternotomy. Her postoperative course was uneventful without recurrent bleeding or infection. Considering the risk of tracheo-innominate artery fistula, careful observation is necessary to prevent catastrophic bleeding in patients with mechanical respiratory support via tracheostomy.

Surgical Experience of Radiation-Induced Coronary Artery Ostial Stenosis / 日本心臓血管外科学会雑誌

Radiation-induced heart disease includes various types of cardiac disorders that occur after thoracic irradiation therapy. The coronary artery has been known to be affected in this kind of pathological condition. A 37-year-old man diagnosed with acute coronary syndrome was referred to our institution. He had received irradiation therapy for mediastinal malignant lymphoma at the age of 10 and 11 years. An extended thymectomy for a thymoma via median sternotomy was performed at 18 years old. He also underwent thoracoscopic pericardial fenestration for a pericardial effusion at 26 years old. Coronary angiography revealed severe stenosis of the left and right coronary ostia. Considering the patient's characteristics, including a history of thoracic irradiation therapy, radiation induced heart disease was suspected as a pathogenesis for severe ostial stenosis of the coronary arteries. He underwent conventional on-pump beating coronary artery bypass grafting (CABG) on an urgent basis. Neither internal thoracic artery was suitable for bypass conduit because of dense adhesion. Therefore, the radial artery and great saphenous vein were used as free grafts for coronary revascularization. Furthermore, partial clamping of the ascending aorta seemed to be difficult and inappropriate owing to severe adhesion, so proximal anastomosis devices were used without a side biting clamp. The postoperative course was uneventful and both bypass grafts were patent. Now, he is doing well 10 years after the CABG without any other cardiac event.

Abdominal Vacuum-Assisted Closure for Secondary Abdominal Fascial Closure into Open Abdomen after Surgical Repair for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Secondary abdominal fascial closure by abdominal vacuum-assisted closure (VAC) therapy is required for abdominal organ protection and prevention of infection due to abdominal compartment syndrome (ACS) developing after the surgery. In this paper, we present our experience with abdominal VAC therapy for two cases that required open abdominal management after surgical repair for ruptured abdominal aortic aneurysm, with favorable outcomes. Case 1 involved a 72-year-old man who underwent endovascular aortic repair for ruptured abdominal aortic aneurysm. Abdominal VAC therapy was started after decompression laparotomy because he developed ACS immediately after surgery. Secondary abdominal fascial closure was performed on day 4 postoperatively, and he had no complications. Case 2 involved a 71-year-old man who underwent emergency Y-graft replacement for ruptured abdominal aortic aneurysm. We considered secondary abdominal fascial closure necessary because of prominent intestinal edema and massive retroperitoneal hematoma, and performed abdominal VAC therapy. We changed the VAC system on day 4, postoperatively and performed secondary abdominal fascial closure on day 7, postoperatively. Abdominal VAC therapy is considered effective and safe for patients requiring secondary abdominal fascial closure after abdominal surgery.

Sartorius Muscle Flap Coverage in Patients with Groin Wound Complications Subsequent to Vascular Surgical Procedure / 日本心臓血管外科学会雑誌

<p>After vascular surgical procedures, complications of the wounds in the groin region may sometimes lead to prosthetic graft infections or prolonged hospital stays. While some wounds heal completely during re-suture and VAC therapy, healing of other wounds that involve refractory graft infection, lymphorrhea, or a dead space, is extremely difficult. We performed tissue coverage using a Sartorius muscle flap for such difficult cases. The muscle is twisted onto itself to fill the dead space with some blood supply. Tissue coverage using a Sartorius muscle flap with adequate blood flow was effective in improving lymphorrhea and infection. We report four such cases where complications in the groin region were managed using a Sartorius muscle flap for wounded coverage.</p>

Aortic Arch Aneurysm 7 Years after Aortic Root Replacement in a Patient of Loeys-Dietz Syndrome / 日本心臓血管外科学会雑誌

<p>A 14-year-old women who had a history of aortic root replacement at 7 years old admitted our hospital due to dilatation of aortic arch aneurysm. Loeys-Dietz syndrome was diagnosed when she was 10 years old. Computed tomography showed 70 mm proximal arch aneurysm. Operative findings revealed brachiocephalic artery and left common carotid artery branched from aneurysm. Partial arch replacement was performed and distal anastomosis was made between left common carotid artery and left subclavian artery. Close observation by CT regularly is necessary and undergo aortic repair not to miss the timing of surgery.</p>

Plasma Levels of D-dimer and Fibrin Degradation Product Could Be Predictors of Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

<b>Objective</b> : Although an endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR), the proper and noninvasive method for the detection of endoleaks is not established. The purpose of this study is to investigate whether plasma levels of D-dimer and fibrin degradation product (FDP) could be predictors of endoleaks after EVAR. <b>Methods</b> : Between June 2011 and January 2014, 65 consecutive patients underwent EVAR at our institution. We evaluated 55 patients excluding 10 patients pre-existing conditions such as aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties in making outpatient visits. Enhanced computed tomography (CT) examination was performed during 12 months after EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up time. Patients were divided into groups according to CT findings at 12 months after EVAR. There were 26 patients with endoleaks vs. 29 non-endoleak patients, 34 with unchanged aneurysm findings vs. 21 with shrinkage. No patient showed aneurysmal enlargement. Plasma levels of D-dimer, FDP, counts of platelet, prothrombin time (PT), and activated partial thromboplastin time (APTT) were also measured at the time of CT examinations. <b>Results</b> : There was no operative death and no major complication. Endoleaks in all patients were identified as type II. None of them required re-intervention. In the endoleak group, plasma levels of D-dimer and FDP were significantly higher than in the non-endoleak group in each postoperative period. In addition, postoperative counts of platelet were significantly lower in the endoleak group. PT and APTT test results showed no significant difference in the two groups. In the unchanged aneurysm group, postoperative D-dimer and FDP tended to be higher compared with the shrinkage group. Postoperative counts of platelet also tended to be lower in the unchanged group. There were no differences in PT and APTT test results. <b>Conclusion</b> : Plasma levels of D-dimer and FDP are potentially useful predictors of endoleaks after EVAR.

A Case Report of Aortic Valve Replacement for a Patient with von Willebrand Disease / 日本心臓血管外科学会雑誌

We report a 30-year-old patient with von Willebrand disease who received AVR under cardio-pulmonary bypass. AR was diagnosed at the age of 13, and von Willebrand disease was revealed after cardiac catheterization because of a bleeding episode. His von Willebrand factor (vWF) activity was significantly low, 43% of normal. Infusion of vWF concentrates (Confact F^®) was administered before surgery. AVR was safely performed and no bleeding complications occurred during the perioperative period. Blood transfusion was unnecessary, vWF infusion was considered to be very useful.

A Rare Case of Leiomyosarcoma Originating from the Abdominal Aorta / 日本心臓血管外科学会雑誌

We report an extremely rare case of leiomyosarcoma originating from the abdominal aorta. The patient was a 57-year-old man who had palpable abdominal mass with pain. The symptoms were consistent, and urgent operation was done due to impending rupture of the abdominal aortic aneurysm. The intraoperative findings showed that the mass was a primary tumor of the abdominal aorta, and the histological diagnosis was leiomyosarcoma. It is reported that its prognosis is very poor, but he survived 7.5 years after diagnosis by reason of aggressive management including surgical treatment, chemotherapy and radiotherapy.

Left Atrial Aneurysm Complicated with Mitral Regurgitation and Severe Heart Failure / 日本心臓血管外科学会雑誌

Left atrial aneurysm (LAA) is extremely rare. We report a surgical case of LAA complicated with mitral regurgitation (MR) and severe heart failure. A 71-year-old man presented dyspnea and leg edema, followed by congestive heart failure. Transthoracic echocardiogram (TTE) showed moderate MR, deteriorated left ventricular function, and echo free space connecting to the posterior wall of the left atrium. Three-dimensional reconstruction of computed tomography (3D-CT) clearly showed the whole shape of the LAA and its location relating to surrounding structures. LAA was 5×6 cm, expanding to apex side, and originated from the posterior wall of left atrium between circumflex branch of the left coronary artery and coronary sinus. LAA wall extended to the mitral posterior annulus, causing annular deformity and MR. Mitral valve plasty and aneurysmorrhaphy were performed. Biventricular pacing leads were implanted for cardiac resynchronization therapy, because of severe heart failure. Postoperative 3D-CT showed reduction of the LAA with no deformity of coronary vessels. No MR was detected by postoperative TTE. The patient has recovered without any complication after our treatments.

Surgical Treatment of Proximal Aortic Dissection in Patients with Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

<b>Objective</b> : Although dissection extending to the aortic root is a common finding, it is potentially fatal in patients with acute type A aortic dissection. The purpose of this study was to evaluate surgical results of acute type A aortic dissection with proximal involvement. The proximal extension of dissection, types of aortic root procedure and its feasibility were investigated. <b>Methods</b> : Between 1997 and 2011, 80 patients with acute type A aortic dissection underwent emergent operation. <b>Results</b> : Dissection reaching around the coronary artery orifice was observed in 28 patients. In 11 patients, both left and right coronary arteries were involved with aortic dissection. Aortic root replacement was performed in 4 patients. In 7 patients, the dissected aortic root was reinforced by GRF glue and proximal aorta was replaced with a graft. Among these patients, postoperative aortic root redissection with severe aortic regurgitation was observed in 5 patients during postoperative long-term periods. All of them required surgical re-intervention of the aortic root. In 17 patients, dissection was extended to the right coronary artery. Aortic root reconstruction was performed in 2 patients due to pre-existing annulo-aortic ectasia. The remaining 15 patients underwent proximal reinforcement with GRF glue. No patient showed dissection extending to the left coronary artery alone. Operative mortality was 11% and other types of complications concerning the aortic root was not observed. <b>Conclusion</b> : An acceptable outcome was demonstrated with our surgical strategy of proximal aortic dissection. For patients, in particular, with proximal involvement to both the left and right coronary arteries, redissection of the aortic root should be noticed as a late complication with considerable frequency. Special care should be taken for precise recognition of the proximal extension of dissection and appropriate surgical procedure including simultaneous aortic root replacement.

Surgical Experience of Superior Mesenteric Venous Aneurysm / 日本心臓血管外科学会雑誌

Superior mesenteric venous aneurysm (SMVA) is rare and no standard treatment protocol has yet been established. We report our experience in performing surgical treatment for SMVA. A 64-year-old man was found to have a SMVA by computed tomography which had been performed during follow-up for gastrectomy. The SMVA was observed to gradually increase in diameter, and surgical treatment was therefore indicated. We successfully resected the aneurysm and then closed the defect with a bovine pericardial patch. Considering the potential risk of rupture, venous aneurysms that present with a saccular shape and an expanding tendency should be immediately surgically treated.

Port-Access Minimally Invasive Cardiac Surgery for Patent Foramen Ovale Complicated with Paradoxical Cerebral Embolism / 日本心臓血管外科学会雑誌

The patient was a 63-year-old man, who had developed cerebral infarction during treatment for sleep apnea syndrome. He also presented typical features of deep venous thrombosis of the right lower extremity. Transesophageal echocardiography clearly showed the blood flow passing through the patent foramen ovale (PFO) followed by Valsalva maneuver. Paradoxical cerebral embolism caused by a PFO was diagnosed. Several procedures were considered to prevent recurrence of cerebral infarction, he underwent PFO closure by minimally invasive procedure, so-called port-access cardiac surgery. He started walking on the day of surgery, and postoperative echocardiography showed no residual shunt flow. Currently, no catheter-based PFO closure device is allowed in Japan, the PFO closure by the port-access technique should be considered as a feasible alternative.

Emergency Redo Aortic Root Replacement for Composite Graft Dehiscence due to Aortitis Syndrome in a Child / 日本心臓血管外科学会雑誌

We report a case of 10-year-old woman with aortitis syndrome who had a graft dehiscence at the site of proximal anastomosis 8 months after aortic root replacement. Because she suffered severe chest compression and ST depression was demonstrated on 12 lead ECG, she was admitted on a suspicion of vasospasmic angina. However, transesophageal echocardiogram and CT showed an echo-free space around the previous operated aortic composite graft, so we concluded that a proximal graft dehiscence and bleeding around it was the cause of her severely deteriorated circulatory condition, and emergency redo aortic replacement was planned. After deep hypothermic circulatory arrest was accomplished, selective cerebral perfusion was performed following re-sternotomy. Previous composite graft was detached at the site of proximal anastomosis, and the aortic annulus was friable and edematous. Redo aortic replacement successful. Laboratory findings revealed uncontrollable aortitis syndrome as the etiologic factor of graft dehiscence. Postoperatively, she was complicated with cerebral infarction due to a stuck valve. She was discharged at 56 postoperative day.

Clinical and Thermographic Findings in the Late Postoperative Period after Coronary Artery Bypass Surgery Using the Radial Artery / 日本心臓血管外科学会雑誌

We evaluated the relation of changes in skin temperature, measured by thermography, to clinical symptoms and findings in patients who underwent coronary artery bypass surgery using the radial artery. All had a negative Allen test before operation. Ten consecutive patients who underwent surgery at least 3 months prior to the study were selected. Left radial artery grafts were harvested in all patients. Skin temperature was measured twice, before and after exercise. Two patients had a cold sensation at the arterial harvest site at rest. Three, including these two, complained of pain along the harvest site after exercise. No differences in temperature were observed before and after exercise in the ulnar aspects of the palm or forearm on either the left or right side. On the other hand, the increase in radial aspect temperature on the left side was smaller than that on the right. Skin temperature was clearly decreased after loaded exercise in 3 patients. We believe that the indications of grafting should be carefully considered because patients can show findings associated with circulatory disturbance at arterial harvest sites.

Reoperation after Corrective Surgery for Right Ventricular Outflow Tract Obstruction / 日本心臓血管外科学会雑誌

In the past 13 years, 17 patients underwent reoperation after intracardiac repair, including reconstruction of the right ventricular outflow tract. Primary diagnoses of the cardic anomalies were tetralogy of Fallot (TOF) (8 patients), extreme type (TOF) (4 patients), TOF with absent pulmonary valve (1 patient), double outlet right ventricle (DORV) (2 patients), truncus arteriosus (1 patient) and transposition of the great arteries (TGA) (1 patient). Patients were divided into 4 groups based on the surgical procedures for reconstruction of the right ventricular outflow tract as follows: Group A, porcine valved conduit; Group B, autologous pericardial valve bearing tube graft; Group C, transannular patch; Group D, outflow patch with pulmomary valvotomy. The main reason for reoperation in groups A and B was pulmonary stenosis due to calcification of the porcine valve or shrinkage of the pericardial tube graft. Average periods between corrective surgery and reoperation were 7 and 13 years in groups A and B, respectively. Reoperation was performed for massive tricuspid regurgitation and residual shunt, 15 and 24 years after previous operations in groups C and D, respectively. Low cardiac output syndrome, proconged right heart and respiratory failure were major postoperative complications in groups A, B and C. Furthermore, one patient in group A and one other in group C died in the long-term period after reoperation. Both patients had had markedly dilated hearts associated with frequent PVCs. In conclusion, earlier reoperation for progressive and/or residual lesions should be performed to obtain better surgical outcome and quality of life of the patients.