An Adult Case of Acute Rheumatic Fever with Valve Destruction, Followed by Successful Valve Replacement / 日本心臓血管外科学会雑誌

<p>Thirty two years-old man with arthralgia in both hands was given with non-steroid anti-inflammatory drug and followed. The symptoms persisted, and hematuria and signs of infection were getting apparent. The patient was referred to our hospital with increasing dyspnea. The patient presented acute heart failure, acute renal insufficiency and respiratory failure. Echocardiography revealed vegetation and regurgitation in the aortic and mitral valve. Blood culture demonstrated α-<i>Streptococcus</i>. CT revealed enlargement of the aortic root. The patient was diagnosed with infectious endocarditis, and referred for surgery. At surgery, the aortic valve and mitral valve were severely destroyed. Aortic root and mitral valve replacement were performed. Pathological findings demonstrated valve destruction as a result of endocarditis due to active rheumatic fever. Clumps of bacteria were not noted around the valves. This is a rare adult case with valve destruction by acute rheumatic fever.</p>

A Successful Treatment for Myonephropathic Metabolic Syndrome and Delayed Intestinal Ischemia after Operation of Acute Type B Aortic Dissection with Bilateral Lower Limb Ischemia / 日本心臓血管外科学会雑誌

A 20-year-old man suddenly complained of back pain and bilateral lower limb weakness. Computed tomography showed acute type B aortic dissection. The patent false lumen extended from distal arch to the left common iliac artery. The true lumen was severely compressed by the false lumen and both legs were ischemic. He underwent emergency fenestration of the abdominal aorta and stenting of the left iliac artery. Although the lower limbs ischemia was improved, he developed myonephropathic metabolic syndrome and received plasma exchange, continuous hemodialysis and endotoxin absorption therapy. Thirteen days after the operation, intestinal ischemia occurred and he underwent emergency bowel resection with creation of a stoma. Development of dissection to the superior mesenteric artery (SMA) and the malperfusion of SMA by severe compression of the true lumen were thought to cause intestinal ischemia.

A Case of Infrarenal Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia / 日本心臓血管外科学会雑誌

Spinal cord ischemia is a very rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms. A 65-year-old man who had a history of CABG (LITA-LAD, LITA-Y composite RA-OM) underwent resection of an abdominal aortic aneurysm. Postoperatively, he developed paraplegia and hypoesthesia with associated fecal incontinence. Reduction of collateral flows of patent lumbar arteries probably caused serious ischemia of the spinal cord. A standard infra-renal abdominal aorta surgery still has the risk of postoperative paraplegia, which should be incorporated in the preoperative informed consent.

Redo Off-Pump Coronary Artery Bypass Grafting through Left Thoractomy Using the Aortic Connector for Proximal Graft Anastomosis on the Descending Aorta / 日本心臓血管外科学会雑誌

A 76-year-old man who had undergone primary coronary operation through a median sternotomy 9 years previously presented with recurrent angina. Preoperative angiography revealed 90% stenosis of the circumflex coronary artery and left subclavian artery. Two saphenous vein grafts (SVG) placed in the previous operation were patent. Redo off-pump CABG was performed through a left thoracotomy approach. The proximal end of the new SVG was connected to the descending thoracic aorta using the St. Jude Medical aortic connector system. The distal anastomosis to the obtuse marginal branch was performed on a beating heart. The postoperative course was uneventful. This case suggested that, in cases requiring the proximal graft anastomosis on the descending aorta, the application of the aortic connector system can be a useful strategy, helping to facilitate the proximal anastomosis and avoid complications associated with the aortic partial-clamping on the descending aorta.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) with Intramural Aortic Route / 日本心臓血管外科学会雑誌

We report a 5-year-old girl with a diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery with an intramural aortic route. The left coronary artery entered the aortic wall running parallel to the aorta. With the aid of cardiopulmonary bypass, she underwent establishment of two coronary artery systems by intraaortic reconstruction (unroofing and anastomosis). Her postoperative course was uneventful. Postoperative cineangiogram demonstrated patency and prograde flow in the new coronary systems.

Clinical Studies of Anticoagulant Therapy by Monitoring of Heparin Concentration / 日本心臓血管外科学会雑誌

The activated clotting time (ACT) is used to assess adequacy of anticoagulation during cardiopulmonary bypass (CPB). However, ACT values during CPB do not correlate with heparin concentration and are affected by variations of such factors as hypothermia and hemodilution. ACT is also used to estimate protamine doses, because excess protamine may result in hypotension and an increase in bleeding after CPB. This study was designed to evaluate the effect of heparin and protamine administration that were administered based on whole blood heparin concentration using Hepcon/HMS (HC group) on the incidence of bleeding and blood transfusion after CPB. We treated 32 of adult cases and 36 pediatric cases. For the control group (NC group), an initial fixed dose of 300U/kg heparin was administered and if the ACT was less than 400s an additional fixed dose of 100U/kg heparin was administered. Heparin was neutralized with an initial fixed dose of protamine. For the HC group, the initial dose of heparin and the additional dose of heparin were based on an automated heparin dose response assay. The initial dose of protamine was based on the residual heparin concentration. The patients in the HC group received greater doses of heparin and lower doses of protamine than the patients in the NC group. In the pediatric HC group, the amount of TAT, FTC and D-dimer post CPB were smaller than those in the NC group. Operative time and closure time were similar the two groups. Operative bleeding, mediastinal chest tube drainage in the postoperative period were similar in the two groups. The volume of total blood transfusion was also comparable in the two groups. In conclusion, the monitoring of heparin concentration during CPB in children was effective for the maintenance of coagulation factors.

A Case of Ventricular Septal Defect and Atrial Septal Defect in an Infant with Right Lung Aplasia / 日本心臓血管外科学会雑誌

This paper describes a very rare case of both ventricular septal defect (VSD) and atrial septal defect (ASD) associated with pulmonary hypertension (PH) successfully repaired via a right thoracotomy in infant with right lung aplasia. A 4-month old infant was admitted to our hospital because of congenital heart disease and right lung abnormalities. Roentogenograms revealed complete opacity of the right hemithorax, with a shift of the mediastinum and the heart to the right. Computed tomography of the chest showed the absence of the right lung and a right bronchus remnant. Therefore, a dignosis of aplasia of the right lung was made at this point. Echocardiogram confirmed VSD and ASD, both of which were 5-mm in diameter, and associated with PH. At the age of 1 year and 7 months, cardiac catheterization was performed, showing pulmonary hypertension with a systolic pulmonary-to-systemic pressure ratio (P_p/P_s) of 0.66. Tolazoline hydrochloride decreased pulmonary vascular resistance (R_p) from 6.92 units·m² to 3.11 units·m². The operation, under cardiopulmonary bypass, was performed via a right thoracotomy approach, because of severe counterclockwise rotation of the heart. VSD and ASD were closed by primary suturing. This approach offered excellent exposure of the intracardiac anatomy in our case. An intraoperative pressure study showed normal pulmonary arterial pressure, the P_p/P_s decreased to 0.33. The postoperative course was uneventful.