A Case of Open Stent Grafting for Thoracic Aortic Aneurysm Combined with Atypical Coarctation and Aortic Regurgitation / 日本心臓血管外科学会雑誌

A 58-year-old woman admitted for further examination of the proximal descending thoracic aortic aneurysm (TAA) combined with atypical coarctation and aortic regurgitation (AR). The chest CT and aortography confirmed these diagnoses, and revealed a pressure gradient of 40mmHg at the descending thoracic aorta with a severe calcification of the aortic wall, and severe AR. We scheduled a one-stage operation for this patient. First, we performed aortic valve replacement. Then we made a graft replacement from the aortic arch to the descending aorta using a stent graft via the aortic arch. Finally we did a reconstruction for lower limb perfusion using an aorto-iliac (extra-anatomical) bypass. The patient is now doing well 3 years after the surgery without any endoleak and without any difference of blood pressure between upper and lower limbs.

Ross Operation for Prosthetic Aortic Valve Endocarditis with Paravalvular Abscess / 日本心臓血管外科学会雑誌

An 18-year-old man underwent a Ross operation for the treatment of prosthetic aortic valve endocarditis with extensive perivalvular tissue destruction. Postoperatively, he developed poststernotomy methicillin-resistant <i>Staphylococcus aureus</i> mediastinitis, which was treated with one-staged irrigation, debridement and omental transfer. After 3 years of follow-up, he is doing well without any sign of infection or a graft failure.

Transaortic Endovascular Stent Grafting: An Acceptable Alternative for Aortic Arch Surgery / 日本心臓血管外科学会雑誌

Endovascular grafting via the aortic arch, a novel alternative method for aortic aneurysm repair, was performed in 18 patients with aortic arch or distal arch aneurysms. For cerebral protection, selective or retrograde cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy. Selective cerebral perfusion was performed through both cerebral arteries and the left subclavian artery. Throughout this procedure, the aorta was filled with carbon dioxide to prevent the spinal arteries from air embolism. Two patients were lost, one due to myocardial infarction and one due to pneumonia. Endoluminal leakage was found in 2 patients, for which reoperation was required. However, no cerebral or spinal complications were observed in this series. Thus we conclude that endovascular stent grafting via the aortic arch is an acceptable alternative for the aortic arch or distal arch aneurysm repair with little risk of cerebral or spinal complications.

A Successful Combined Aortic and Mitral Valve Replacement after Renal Transplantation / 日本心臓血管外科学会雑誌

A combined aortic and mitral valve replacement was performed in a 50-year-old man who had undergone living-related renal transplantation one year previously. The oral administration of tacrolimus was continued perioperatively while monitoring blood tacrolimus level. The postoperative administration of human atrial natriuretic peptide (hANP) was effective to maintain urine output was performed in addition to frosemide, mannitol, dopamin and prostaglandin E₁ infusions. He was discharged on the 37th postoperative day without rejection, infection or renal dysfunction. This is the first report in Japan describing successful combined aortic and mitral valve replacement after renal transplantation.

Forearm Problems after CABG Using Radial Artery Grafts / 日本心臓血管外科学会雑誌

There have been many reports radial artery grafts (RA) are useful in CABG, but there were very few reports about hand grasping power (GP), edema and sensory disturbance after surgery. From January to April, 1999, RA were used for 14 patients (R group) and were not in 16 patients (C group) among a total of 30 coronary artery bypass grafting procedures. The patients in the two groups were statistically similar. RA were anastomosed to #12 in 9 patients and #14 in 5. GP and the circumference of forearms were examined and sensory disturbance was also checked preoperatively and at 1, 2 and 4 weeks postoperatively. In both groups, left GP decreased slightly after surgery but gradually recovered. Four weeks after surgery, it was 26.2±9.6kg in the R group and 26.2±7.5kg in the C group (NS). The difference between left and right circumference of forearms, which indicates the degree of edema, was significantly larger in the R group than in the C group (3.5±3.6mm vs. -0.5±3.8mm, 1 week postoperatively, <i>p</i><0.05). However, it gradually improved in the R group (2.1±2.6mm at 2 weeks and 1.9±2.6mm at 4 weeks postoperatively). No sensory disturbance was seen at any time. Therefore we conclude that using RA in CABG is not only useful but is also safe and does not increase postoperative risk.

Case Report of CABG Undergone in a Patient with Malignant Hyperthermia Risk and AT III Deficiency / 日本心臓血管外科学会雑誌

Malignant hyperthermia (MH) and antithrombin III (AT III) deficiency are both rare, but once they occur, the patient's prognosis is very poor. A 67-year-old man was referred to our hospital with a diagnosis of unstable angina. A coronary angiography revealed stenosis of LMT and triple vessels. The patient was considered a candidate for CABG. He had been prescribed 50mg/day of dantrolene for frequent muscular convulsions of the lower extremities. He had had a high CK level for a few years. Therefore he was considered to be at high risk for malignant hyperthermia (MH). He underwent CABG (×4). Dantrolene was administered orally at a dose of 25mg and then 160mg intravenously before anesthesia and modified NLA was performed in order to avoid probable MH. During the operation, AT III deficiency was suspected because the reaction of ACT after heparinization was poor. AT III preparation (1, 500 units) was used and CABG under cardiopulmonary bypass was completed without any events. It was proved after the surgery that the AT III volume had been almost normal but its activity had decreased. His postoperative course was good. For possibly fatal MH and AT III deficiency, it is necessary and important to predict, prevent and diagnose as early as possible.

Risk Factors and Treatment for Mediastinitis in Internal Mammary Artery Grafting, with Particular Regard to Diabetic Patients / 日本心臓血管外科学会雑誌

The internal mammary artery (IMA) has been widely used in CABG due to the excellent long-term results. However, the extensive use of bilateral IMA grafting has been believed to increase operative morbidity and mortality. This study was designed to determine if bilateral IMA grafting in diabetic patients increased the likelihood of mediastinitis. We analyzed the data of 386 consecutive patients who underwent isolated CABG in 1992 to 1996. The definitions of sternal wound complications are as follows, (1) mediastinal dehiscence and (2) mediastinal wound infection. Subtypes include superficial wound infection and deep wound infection (mediastinitis). Among these patients 97 received unilateral IMA grafts and 289 did bilateral IMA grafts. mediastinitis did not occur in any subjects. The occurrence rate of mediastinal dehiscence and superficial wound infection was 7.2% (7/97) for bilateral IMA grafting, 7.3% (21/289) for unilateral IMA grafting. No patients died of wound complications. The occurrence rate of mediastinal dehiscence and superficial wound infections were 12.0% (4/33) for bilateral IMA grafting in diabetic patients, 12.0% (14/117) for unilateral IMA grafting in diabetic patients. That of this complications was 4.7% (3/64) for bilateral IMA grafting in non-diabetic patients, 4.1% (7/172) for unilateral IMA grafting in diabetic patients, without significant differences in wound complication. Bilateral IMA grafting in diabetic patients carried no great risk of mediastinitis, but diabetes mellitus itself was a great risk for mediastinitis.

A Case of Video-Assisted Thoracoscopic Surgery for Clipping the Patent Ductus Arteriosus in a Child / 日本心臓血管外科学会雑誌

We performed a video-assisted thoracoscopic surgery (VATS) to clip the patent ductus arteriosus (PDA), which was 5mm in internal diameter, in an 11-year-old girl, who first underwent a coil embolization ending in failure. Under general anesthesia with one-lung ventilation in a right lateral decubitus position, four thoracostomies were made in the left hemithorax. The PDA was clipped by two titanium clips, the length of which is 11mm at closing. Transesophageal echocardiography confirmed the location of the PDA and the absence of a residual shunt. The patient showed neither left recurrent laryngeal nerve dysfunction nor hemorrhage after operation, and was discharged on the 9th postoperative day. The clipping of the PDA by VATS can be applied for PDA without calcification if the external diameter is up to 7mm. This technique was minimally invasive and reliable. It was excellent in terms of the high quality of life achieved by the patient.

A Case Report of Mediastinitis after Subtotal Graft Replacement of the Thoracic Aorta / 日本心臓血管外科学会雑誌

A 57-year-old man underwent subtotal graft replacement of the thoracic aorta for aneurysms of both the ascending and descending aorta. On the 20th post-operative day, pus was found to be draining from the sternotomy wound. The wound was opened and irrigated with 2% Povidoneiodine solution for a total of 3 months. Culture of the pus from the irrigation revealed <i>Staphylococcus epidermidis</i>. When there were no clinical indications of infection and wound cultures were negative, the necrotic sternum and surrounding tissue were debrided and an omental graft was placed in the cavity. Upon follow-up examination, the patient is doing well 10 months after the initial surgery.

A Case of Proximal Descending Aortic Aneurysm with Floating Mural Thrombi Detected by Intraoperative Direct Echography / 日本心臓血管外科学会雑誌

We treated a 62-year-old man with aneurysms of the descending thoracic aorta (45mm: proximal, 60mm: distal). We evaluated the intima of the aorta by intraoperative direct echography using a small probe (finger tip size), which detected floating mural thrombi in the proximal descending aorta. Therefore we chose the proximal and distal open technique with retrograde cerebral circulation under deep hypothermia during graft replacement of the descending aorta. There was no complication during or after surgical treatment.

Surgery for Aortic Valve Disease Combined with Coronary Artery Disease and Arrhythmia / 日本心臓血管外科学会雑誌

Aortic valve disease is frequently associated with coronary artery disease and arrythmia. Recently, the mortality of aortic valve replacement has decreased because of more effective myocardial protection, so operations that combine aortic valve replacement and coronary bypass grafting or the Maze procedure for atrial fibrillation have been performed. We treated 25 patients undergoing aortic valve replacement combined with coronary bypass grafting and 2 patients undergoing aortic valve replacement with a modified Maze procedure from 1990 to 1996. Among the patients undergoing aortic valve replacement combined with coronary bypass grafting, there were no perioperative deaths and no development of coronary artery disease, malfunction of mechanical valve, or thrombosis. Two patients undergoing aortic valve replacement with a modified Maze procedure and tricuspid valve annuloplasty have reverted to sinus rhythm from atrial fibrillation with no anti-arrythmic agent. Surgery for combined aortic valve disease and coronary artery disease or arrythmia resulted in an improvement of late survival and quality of life.

A Case of Acute Bowel Necrosis Caused by Ischemia of the Lower Half of the Body at 9 Years after Aortic Arch Replacement / 日本心臓血管外科学会雑誌

A 60-year-old man who had undergone aortic arch replacement 9 years prerviously was admitted complaining of motor and sensory disturbance of bilateral lower extremities. Bilateral femoral arteries were not palpable and he showed acute panperitonitis just after admission. Enhanced CT and arteriography revealed that the lower half of the body was severely ischemic due to the compression of the graft by a pseudoaneurysm of the proximal anastomotic portion of the aortic arch, and therefore performed an urgent operation. Recognizing acute bowel necrosis of the inferior mesenteric artery (IMA) area on laparotomy, Hartmann's operation was performed. After that, a right axillo-bifemoral bypass was also made in order to improve the perfusion of the lower half of the body. Though acute renal failure occurred because of DIC and myonephropathic metabolic syndrome (MNMS) postoperatively, the intensive therapy was eventually effective and he recovered.

Two cases of bilateral phrenic nerve paralysis following cardiac surgery / 日本心臓血管外科学会雑誌

Two cases of bilateral phrenic nerve paralysis were reported. The first case was a 51-year-old male who underwent mitral valve replacement for mitral valve regurgitation. Upon extubation he was noted to have the paradoxical breathing pattern associated with bilateral phrenic nerve paralysis. He was treated conservatively, keeping him in a sitting position without reintubation or tracheostomy. The patient recovered from the paradoxical breathing pattern by the tenth post-operative day. The second patient was a 66-year-old male who underwent mitral valve replacement and CABG for mitral valve regurgitation and angina pectoris. Upon extubation this patient was also noted to have a paradoxical breathing pattern. Conservative treatment was initiated. This patient suffered from sudden apneic episode followed by cardiac arrest on 17th post-operative day. Cardio-pulmonary resuscitation was successful, however, the patient was noted to have extensive ischemic brain damage after resuscitation. The patient died approximately one year later from respiratory failure. Generally speaking, the cause of phrenic nerve paralysis after cardiac surgery is cold injury from ice slush used for topical cardiac cooling. However, direct mechanical injury to the right phrenic nerve might result from the proximity of the right phrenic nerve to the left atrial suture line of a mitral valve replacement.