A Case of Giant Unruptured Left Coronary Sinus of Valsalva Aneurysm / 日本心臓血管外科学会雑誌

A 40-year old man with chest pain was admitted to our hospital. A three-dimensional CT revealed an unruptured left coronary sinus of Valsalva aneurysm and mild stenosis of the left main trunk. An echocardiogram revealed severe aortic regurgitation. He was operated on with an aortic root replacement procedure. Though the procedure was itself uneventful, he could not be weaned from cardiopulmonary bypass because of unexpected coronary events ; relative stenosis of the RCA and stretched LMT due to a huge aneurysm of the sinus of Valsalva. Additional CABG with LITA to LAD and SVG to RCA led to weaning from cardiopulmonary bypass. Left coronary sinus of Valsalva aneurysm is rare, and it requires early surgical intervention for an increase in the diameter of the aneurysm together with myocardial ischemia due to compression of the coronary artery.

Tricuspid Valve Replacement in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries and Situs Inversus / 日本心臓血管外科学会雑誌

A 62-year-old woman was admitted to our hospital because of dextrocardia on her chest X-ray film. She had been in good health though the X-ray abnormality had been pointed out from her childhood. Echocardiogram, magnetic resonance imaging, and cardiac catheterization revealed situs inversus, congenitally corrected transposition of the great arteries, and severe tricuspid valve (systemic atrioventricular valve) regurgitation with mild systemic ventricular dysfunction. The surgeon stood on the patient's left side during the operation. On cardiopulmonary bypass, the tricuspid valve, facing almost dorsally, was exposed through a superior transseptal approach. Tricuspid valve replacement with a mechanical valve was performed with leaflet preservation. Systemic ventricular function is preserved at one year after operation.

Early Clinical Results of On-Pump Beating-Heart versus Off-Pump Coronary Artery Bypass Grafting in Patients with Acute Coronary Syndrome / 日本心臓血管外科学会雑誌

Emergency coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) is still associated with high mortality and morbidity, and early outcome is poor compared with outcome in patients with stable angina. The purpose of this study was to examine the clinical results of on-pump beating heart CABG vs. off-pump coronary artery bypass (OPCAB) for ACS patients. From a total of 432 CABG patients, we retrospectively analyzed 72 (16.7%) patients who underwent emergency CABG between 2004 and 2008. Emergency CABG cases were divided into 2 operative groups : an on-pump beating-heart CABG group (on, <i>n</i>=31) and an OPCAB group (off, <i>n</i>=41). A preoperative history of acute myocardial infarction (AMI), detection of troponin T, preoperative creatine phosphokinase (CPK) value, low ejection fraction, presence of mitral regurgitation (MR) (>II) and cardiomegaly were markedly higher in the on group. There were no statistically significant differences in intraoperative factors. In-hospital mortality was 3.2% (1 patient) in the on group and 7.3% (3 patients) in the off group. Furthermore, statistically significant differences were found between the 2 groups in incidence of all-cause morbidity (on=71.0% : off=41.5%, <i>p</i>=0.01), respiratory failure (on=58.1% : off=29.3%, <i>p</i>=0.01), ICU stay (on=6.5±4.6 days : off=4.1±3.2 days, <i>p</i>=0.01), and necessary inotropic support (on=51.6% : off=17.1%, <i>p</i>=0.02). Multivariate regression analysis of preoperative and intraoperative factors was performed to identify independent factors for in-hospital mortality and morbidity. On multivariate analysis of preoperative factors, only the pre-CPK value reached statistical significance as an independent factor for in-hospital mortality and morbidity.

Vacuum-Assisted Closure Technique to Avoid Abdominal Compartment Syndrome and Infection : A Successful Treatment of an Infected Abdominal Aortic and Left Common Iliac Aneurysms Complicated by MSSA Psoas Abscess / 日本心臓血管外科学会雑誌

The patient was a 68-year-old woman with chief complaints of severe lumbago, left lateral abdominal pain and high fever. Computer tomography (CT) at a local hospital showed a left psoas abscess and a low density area around the terminal aorta. Blood tests indicated a high inflammatory response and MSSA was detected in a blood culture. Control of the infection was first attempted with antibiotics, but CT showed a pseudoaneurysm at the terminal aorta, and therefore she was transferred to our hospital. We diagnosed infected abdominal aortic and left common iliac aneurysms complicated by an MSSA psoas abscess, and performed extra-anatomic reconstruction with axillo-bifemoral bypass, aneurysmectomy and omentopexy in the psoas abscess cavity. Because of massive intestinal edema and mesentery, we attempted temporary abdominal closure with the vacuum-assisted closure (VAC) technique, and finally succeeded in closing without abdominal infection in the 6th operation, 42 days after the first operation. Infected abdominal aortic aneurysm complicated by psoas abscess is extremely rare and life threatening. The VAC technique is very effective not only in avoiding abdominal compartment syndrome but also in avoiding abdominal infection.

Successful Surgical Treatment of Aortic Valve Endocarditis with a Pseudoaneurysm of Ascending Aorta / 日本心臓血管外科学会雑誌

A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20 mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.

A Case of Femoro-Iliac Cross-Over Vein Bypass with a Ringed ePTFE Graft for Common Iliac Venous Thrombosis / 日本心臓血管外科学会雑誌

A 71-year-old man had sudden onset of left lower limb swelling and consulted an orthopedic surgeon 14 days later. Venous echography demonstrated compression of the left iliac vein and the thrombus of the common iliac vein. After emergency admission, conservative therapy was given for 7 days, but the symptoms did not sufficiently diminish and a thrombus was also present. We therefore performed femoro-iliac cross-over vein bypass using a 10mm ringed ePTFE graft. Symptoms were completely improved and the graft was shown to be patent by echography after 3 months.

Assessment of Pulse Wave Velocity as a Marker of Postoperative Cardiovascular Risk in CABG Patients / 日本心臓血管外科学会雑誌

Pulse wave velocity is widely used as an index of arterial stiffness. The aim of this study is to assess the usefulness of pulse wave velocity as a risk factor in patients who underwent coronary artery bypass grafting. Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV) and the ratio of the patient's baPWV to the age-matched normal value was calculated in 42 CABG patients. Age and male/female ratios were 66.7 years and 33/9, respectively. baPWV (1, 820.7±459.8cm/s) was higher in CABG patients than that in age-matched normal value. Preoperatively, the baPWV ratio in the group with the history of cerebrovascular disease was significantly higher than that in the group who had no cerebrovascular disease (<i>p</i><0.05). In contrast, the baPWV ratio did not correlate to the severity of other cardiovascular diseases. There was one (2.4%) in-hospital death and 23 incidences of postoperative complication in 16 patients. The baPWV ratio in the group with postoperative complications was significantly higher than that in the group with no complications (1.38±0.33 vs. 1.16±0.22; <i>p</i><0.05). In this study, baPWV in CABG patients was higher compared with that in the age-matched general population, indicating the existence of atherosclerotic vascular changes. The elevated bePWV is also a risk factor of postoperative complications in patients who have undergone CABG.

A Case of Popliteal Artery Entrapment Precisely Imaged by Multi-Scan Computed Tomography / 日本心臓血管外科学会雑誌

A 16-year-old high school boy experienced intermittent claudication of his left lower limb during boxing training. Physical examination revealed a cold left foot and diminished pulse. A 64-row multi-slice CT (MSCT) demonstrated lateral shift and severe stenosis of the left popliteal artery due to malposition of the medial head of the gastrocnemius muscle. A diagnosis of popliteal artery entrapment syndrome (Delaney type II) was established and a surgical correction was planned. During surgery, since the artery was found to be compressed but not occluded, we simply released the popliteal artery by division of the medial head of the gastrocnemius and abnormal flips of muscle. The postoperative ankle brachial pressure index rose from “not measurable” to 1.22. MSCT was useful to characterize this anomaly by expressing the precise anatomical relation of muscle, bone and artery, which was a good guide for an appropriate surgical intervention.

Preoperative Risk Factors for Residual Aortic Regurgitation after Valve Re-Suspension Procedure in Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

This study evaluated factors influencing residual aortic regurgitation (AR) after valve re-suspension surgery for acute type A aortic dissection. From January 1996 through December 2002, 63 patients were treated for acute type A dissection at our institution. Among these 63 patients, pre-and postoperative echocardiograms were available in 38 patients who underwent surgery combined with native aortic valve re-suspension. These 38 patients were divided into 2 groups according to the postoperative AR grade, i. e.: AR group: AR grade≥II (<i>n</i>=6), no-AR group: AR grade≤I (<i>n</i>=32). The severity of pre and postoperative AR was assessed by transthoracic or transesophageal echocardiography. The preoperative diameters of mid ascending aorta and sinotubular junction, and the percentage of the circumference of the dissection at the sinotubular junction level was measured by enhanced CT scan. Preoperative patient backgrounds were similar in both groups. The preoperative AR grade in the AR group was significantly greater than that of the no-AR group (2.25±1.17: 0.69±0.91, <i>p</i><0.001). The tear was more frequently located in the ascending aorta in the AR group than in the no-AR group (66.7%: 37.5%, <i>p</i><0.05). The percentage of circumference of the dissection at the sinotubular junction level did not affect the preoperative AR grade, but it did show a tendency to influence the severity of postoperative AR, though the difference was not significant. Three patients (7.9%) had AR grade III at the time of discharge, but did not clinically require further surgical intervention. Preoperative significant AR and the location of the tear in the ascending aorta are associated with postoperative residual AR after aortic valve re-suspension. The percentage of circumference of the dissection at the sinotubular junction level might influence the severity of postoperative AR.

A Case of Severe Aortic Stenosis Accompanied by Porcelain Aorta Treated with an Apicoaortic Valved Conduit / 日本心臓血管外科学会雑誌

The patient was a 70-year-old woman with severe aortic stenosis and familial hyperlipidemia which was diagnosed in 1994. The patient was admitted as an emergency case due to syncope in 2002. According to ultrasound cardiography (UCG), the pressure gradient of the aortic valve was 120.7mmHg, and the diameter of the aortic valve annulus was 16.7mm. Computed tomography showed porcelain aorta from the annulus of aortic valve to the ascending aorta. On cardiac catheterization, the pressure gradient was 96mmHg, AVA was 0.4cm², and the ejection fraction was 38.7%. Since these findings suggested that conventional AVR was difficult, thoracotomy was performed at the left 5th intercostal level, and apicoaortic valved conduit (valved graft: SJM19HP, Intergard 22mm+Medtronic apical LV connector) was implanted. Postoperative cine MRI showed that most of the cardiac output (87%, 3.29<i>l</i>/min) flowed through the conduit, with the flow via the aortic valve accounting for 13%, 0.51<i>l</i>/min. This surgical procedure can be an effective alternative when conventional AVR is difficult.

Endovascular Stent-Grafting in a Patient with Concomitant Descending Thoracic Aortic Aneurysm and Cancer of the Right Lung / 日本心臓血管外科学会雑誌

A 75-year-old woman underwent endovascular stent-grafting for a descending thoracic aortic aneurysm, followed by video-assisted thoracoscopic right upper lobectomy for concomitant lung cancer in a later procedure. Two custom-made endovascular spiral Z stents covered with woven Dacron (DuPont Co., Wilmington, DE, USA) were delivered via the femoral artery under local anesthesia using pull-through technique. Intraoperative angiograms showed successful exclusion of the aneurysm without any endoleakage. Conventional surgical treatments for both diseases in this patient would have required bilateral thoracotomy either in a simultaneous or staged fashion and entail risks of postoperative pulmonary dysfunction and progression of the cancer. Endovascular stent-grafting offered potential superior operative results and quality of postoperative life in this patient with concomitant descending thoracic aortic aneurysm and cancer of the right lung.