Impact of Frailty on the Course and Walking Ability after Cardiac Surgery / 日本心臓血管外科学会雑誌

Objective: Frailty has been noticed as an important preoperative risk factor for cardiac surgery. The purpose of this study was to evaluate the effect of frailty on the rehabilitation process and walking ability after cardiac surgery. Methods: A total of 213 patients aged 65 years or older who underwent elective cardiac surgery at our hospital between August 2018 and October 2020 and who underwent a preoperative frailty assessment were included. The patients were divided into two groups: group F with frailty and group N without frailty, and the perioperative factors, postoperative course, and walking ability in both groups were examined. Results: Of all patients, 70 (33%) were diagnosed as frail. In the preoperative factors, gait speed and grip strength were significantly lower in group F, and there were more cases of sarcopenia and malnutrition. There was no significant difference in surgical factors between the two groups, except for a bias in the surgical category. In the postoperative course, there were no significant differences in intubation time, ICU stay, postoperative complications, or hospital stay between the two groups, but more patients in group F were transferred to another hospital. In the F group, the start of walking and the day of achieving 100 m walking were significantly delayed, and the number of patients who achieved 300 m walking was 52 (74%), which was significantly lower than 197 (89%) in the N group. The cutoff value of gait speed was 0.88 m/s. Conclusions: Frailty was associated with delayed rehabilitation and reduced walking ability after cardiac surgery, and increased hospital transfers. In addition, the preoperative gait speed was adopted as one of the factors related to the possibility of a 300 m walk after surgery. We believe that preoperative rehabilitation is a promising strategy to improve the condition of frail patients who require cardiac surgery.

Endovascular Repair of a Secondary Aortoenteric Fistula / 日本心臓血管外科学会雑誌

A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.

A Case of Left Main Trunk (LMT) Obstruction after Aortic Valve Replacement (AVR) Using Carpentier-Edwards PERIMOUNT MAGNA / 日本心臓血管外科学会雑誌

We reported a 74-year-old female complicated by ostial obstruction of the left main trunk after aortic valve replacement for severe aortic stenosis. At surgery, the length from the orifice of the left main trunk to the aortic annulus was 3 mm. After a 19 mm Carpentier-Edwards PERIMOUNT MAGNA was implanted in supra-annular position, the orifice of left main trunk was concealed by a sewing cuff of the bioprosthesis. Before aortic declamping, saphenous vein graft was bypassed to the left anterior descending artery. The postoperative course was uneventful. Computed tomography demonstrated the ostial obstruction of the left main trunk by the bioprosthesis.

The Effectiveness of Early Rehabilitation after Cardiac Surgery / 日本心臓血管外科学会雑誌

The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : <i>n</i>=73) and group B (the early rehabilitation group : <i>n</i>=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (<i>p</i><0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (<i>p</i><0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (<i>p</i><0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (<i>p</i><0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (<i>p</i><0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (<i>p</i><0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (<i>p</i>=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.

Aortic Valve Replacement in Patients Aged 80 or Older / 日本心臓血管外科学会雑誌

With the progressive aging of the Japanese population, cardiac surgeons are increasingly faced with elderly patients. We have studied 29 consecutive patients, 80 years of age or older, who underwent aortic valve replacement at our institution between January 2000 and December 2003. Mortality, morbidity and late follow-up results were compared to those in 36 patients aged from 64 to 75 years old undergoing the same procedure over the same time period. The older patient group had a significantly higher incidence of calcified aortic stenosis and emergency operations and a higher score of NYHA functional class. Hospital mortality was 2 of 29 (6.9%) in the older patient group and 2 of 36 (5.6%) in the control group (ns). Postoperative renal failure and respiratory failure which needed prolonged ventilator support occured significantly more often in the older patient group. However, there was no significant difference between the 2 groups in terms of hospital stay. Almost all octogenarians showed improved NYHA functional class to class I or II after the operations. The actuarial survival rate was 89% in the older patient group and 78% in the control group at 3 years. The late survival rate and cardiac event-free rate were not significantly different between these 2 groups. Following aortic valve replacement, octogenarians, despite more compromised pre-operative status had good relief of symptoms, a favorable quality of life and a similar late survival to the younger patient groups. These findings support the recommendation that valve replacement should be performed in octogenarians with symptomatic aortic valvular disease.

Staged Operation for a Patient with Ischemic Heart Disease and Abdominal Aortic Aneurysm Complicating Idiopathic Thrombocytopenic Purpura / 日本心臓血管外科学会雑誌

A 62-year-old man, who had been given a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital for an operation for abdominal aortic aneurysm (AAA). Preoperative coronary angiography revealed severe triple vessel disease, and we chose to treat this first. The platelet count on his first admission was 2.1×10⁴/μl and preoperative immunoglobulin infusion was introduced for 5 days. Off-pump coronary artery bypass grafting (OPCAB) was performed safely with platelet transfusion, and he was discharged on the 14th postoperative day. Thirty-eight days later, graft replacement of AAA was performed with preoperative immunoglobulin infusion and no platelet transfusion, and he was discharged at the 11th postoperative day. Preoperative immunoglobulin infusion therapy and selection of OPCAB were useful to prevent perioperative bleeding complications. This is the first report of staged cardiac and aortic surgery in a patient with ITP.

A Case of Successful Transaortic Endovascular Stent Grafting for Distal Aortic Arch Aneurysm with Severely Calcified Chronic Aortic Dissection / 日本心臓血管外科学会雑誌

A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.

Malignant Hyperthermia after Surgical Repair of Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO₂, low level of PaO₂ and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/<i>l</i> and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.

A Case of Huge Aortic Arch Aneurysm with Unrevealed Aortopulmonary Fistula Resulting Intraoperative Pulmonary Artery Rupture after Total Arch Replacement / 日本心臓血管外科学会雑誌

A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.

Nonocclusive Mesenteric Ischemia after Off-Pump CABG / 日本心臓血管外科学会雑誌

An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.

A Case of Myocardial Abscess Complicating Mitral Valve Infective Endocarditis due to Klebsiella pneumoniae / 日本心臓血管外科学会雑誌

A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. <i>Klebsiella pneumoniae</i> was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.

Successful In Situ Repair for Mycotic Aneurysm of the Iliac Artery with Autologous Superficial Femoral Vein / 日本心臓血管外科学会雑誌

A successfully treated case of a 73-year-old man with mycotic aneurysm of the iliac artery combined with psoas abscess was reported. The operation consisted of débridement of the infected arterial wall with arterial reconstruction using autologous reversed superficial femoral vein and wrapping the graft and filling the defects with omentum. <i>Streptococcus pneumoniae</i> was grown from the psoas abscess culture. He had peritonitis by gangrenous cholecystitis postoperatively and underwent reexploration for correction of the peritonitis. After his second operation, the postoperative course was uneventful. He is doing well 18 months postoperatively. Venous morbidity after superficial femoral vein harvest is minimal. <i>In situ</i> reconstruction with autogenous deep leg veins is a successful option in patients with mycotic aneurysms.

Strategy for Stanford Type A Acute Aortic Dissection with Thrombosed False Lumen of the Ascending Aorta / 日本心臓血管外科学会雑誌

From 1995 till 1998, 21 cases of Stanford type A dissecting aortic aneurysm with a closed false lumen of the ascending aorta were treated in our institute. The patients were medically treated if the diameter of their ascending aorta stayed less than 50mm without recurrent dissection. Patients were categorized into three groups: Groups I, II and IIIR (retrograde dissection), according to the location of the entry analyzed by means of CT, angiography and operative findings. Seven cases of intramural hematoma (IMH) were included in this study. One case in Group II died of rupture and one case in Group IIIR died of multiple embolism caused by atrial fibrillation in the acute phase. One case in Group II died of stroke and one case in Group I died after surgery in the chronic phase. Four cases in Group I and II underwent surgery in the acute phase and five cases in Group I and II underwent surgery in the chronic phase, but only one case of Group IIIR required surgery. Six cases of IMH required surgery. The rates of freedom from operation at four years was 25%, 21% and 83% respectively (<i>p</i>=0.07). Essentially, Stanford type A dissection should be treated surgically even though the false lumen is thrombosed. However, in the case of retrograde dissection accompanied by an entry in the descending aorta, medical treatment may be a strategy option.

Aneurysms Arising from a Knitted Dacron Velour Graft Which Caused Acute Arterial Embolization / 日本心臓血管外科学会雑誌

A 67-year-old man suffered acute arterial occlusion caused by emboli from aneurysms in a right axillo-bifemoral graft using Cooley double velour knitted Dacron, which was inplanted 10 years and 10 months before the admission. The patient underwent urgent redo surgery; left axillobifemoral bypass with 6mm ringed PTFE graft and right femoropopliteal bypass with <i>in situ</i> saphenous vein were performed successfully. Several clinical experiences by others demonstrated that Cooley double velour knitted Dacron graft, manufactured before June, 1981, might have possible aneurysmogenic factors, therefore cases in which it has been employed should be followed up carefully.

Peroneal Artery Bypass Grafting through a Median Approach in Two Cases of Thromboangitis Obliterans / 日本心臓血管外科学会雑誌

In two cases of thromboangitis obliterans (TAO) a popliteal-posterior tibial-peroneal artery sequential bypass was attempted through a median approach. The 1st case underwent the operation successfully with non-reversed saphenous vein graft. However, only popliteal-peroneal bypass was carried out in the 2nd patient because the posterior tibial artery was severely affected. In surgery of TAO patients, careful assessment of preoperative angiographic findings is important to select the site of distal anastomosis. We found that the posterior tibial artery and the peroneal artery are easily accessible through the medial route in the proximal half of the lower leg and that peroneal artery revascularization was effective for limb salvage.

Surgery of Descending Thoracic Aortic Aneurysms with Use of a Centrifugal Pump. Usefulness of the Autotransfusion System / 日本心臓血管外科学会雑誌

We reviewed the results of 14 patients who underwent the operation of thoracic aneurysms using a centrifugal pump. Nine patients had atherosclerotic aneurysms and 5 had aortic dissections. The autotransfusion system (ATS) was used to keep hemodynamic stability by rapid transfusion. The ATS consisted of a roller pump, a 2, 000ml reservoir and a heat exchanger. Two mg/kg of heparin was given to the patients to keep ACT over 400 seconds. All patients survived. Body temperature increased 0.08±0.59°C during bypass with the ATS, and no patients showed hemodynamic instability after aneurysmotomy under the help of the ATS. We conclude that 1) the centrifugal pump is a useful and safe assisting means for the surgery of thoracic aneurysms, 2) the autotransfusion system has advantages as follows: keeping stable circulation and preventing loss of body temperature during bypass.