ABSTRACT
A 35-year-old man was referred to our hospital for surgical repair of grade IV/IV aortic regurgitation secondary to a congenital unicuspid aortic valve accompanied by aneurysm of the ascending aorta. The aortic valve was the unicuspid unicommissural type and a fully developed commissure was located in the left lateral position (left coronary/right coronary). The anterior (non-coronary/right coronary) and posterior (non-coronary/left coronary) borders were rudimentary with calcified raphe. We performed aortic valve repair in combination with valve sparing root replacement (reimplantation) and partial arch replacement. We converted the unicuspid into a bicuspid aortic valve by preserving his own free margin tissue and creating a neocommissure to the 180 degrees opposite side of the left lateral commissure at the same height by enlarging the cusp with a glutaraldehyde-treated autologous pericardium patch to the cusp belly. The patient was discharged on the 17th postoperative day with trace aortic regurgitation. We successfully repaired the unicuspid aortic valve by augmenting the cusp size using a pericardium patch in order to preserve the free margin of the cusp.
ABSTRACT
A 67-year-old man with ascending aortic aneurysm was referred to our hospital. Transthoracic echocardiography showed severe aortic regurgitation with annuloaortic ectasia and transesophageal echocardiography revealed a quadricuspid aortic valve. This patient underwent aortic root replacement with a valve sparing technique. Under deep hypothermic circulatory arrest with retrograde cerebral perfusion, replacement of the ascending aorta was successfully performed. The postoperative course was uneventful. This patient is doing well 6 months after surgery without recurrence of aortic regurgitation.
ABSTRACT
Idiopathic hypereosinophilic syndrome (IHES) is a rare systemic disease, but frequently associated with the eosinophil-infiltrated end organ (cardiac, hematologic, cutaneous, neurologic, pulmonary, splenic and thromboembolic) failure. Mechanical valve replacement for valvular heart disease in cases of IHES has the potential of thromboembolic accidents in the early post-operative period, even though the strict anti-coagulant therapy was performed. We reported a younger IHES case with congestive heart failure due to severe mitral regurgitation who underwent mitral valve repair instead of replacement. In this case, only the lateral scallop of the posterior mitral leaflet was involved with endocarditis due to the eosinophyl infiltration, with no other symptoms, i.e., initial hyperplasia and thrombus in the left ventricle that were detected in the most cases with IHES endocarditis. Mitral annuloplasty with the complete ring was simply performed because of the presence of sufficient intact anterior leaflet. The eosinophil count had been strictly controlled with imatinib mesilate in addition to the anti-coagulant therapy, and any thromboembolic event had been detected post operatively. In case of valvular heart disease due to IHES endocarditis, valve repair should be firstly attempt and imatinib mesilate is very useful and effective for preventing from post-operative thromboembolic accidents in FIP1L1-PDGFRα gene positive cases.
ABSTRACT
Destructive aortic valve endocarditis or poor controlled aortitis cause the development of left ventricular-aortic discontinuity. We reported our experience with aortic root replacement for cases of severe aortic annular destruction. Between 1999 and 2006, 9 patients with severe aortic annular destruction underwent aortic root replacement at our institute. There were 8 men and one women with a mean age of 55 years. Seven patients were in New York Heart Association functional class III. Four of 9 patients had native valve endocarditis, 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2, aortic root replacements in 2) and one had active aortitis with a detached mechanical valve. Radical debridement of the infected cavity and necrotic tissue was performed in all cases, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 3 cases. Antibiotic-saturated fibrin glue was applied to the cavity. Aortic root replacement was achieved with a pulmonary autograft (Ross procedure) in 4 and stentless aortic root xenograft in 4. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary implantation method. No mortality was observed during hospitalization and follow-up. Reoperation within 5 years was not necessary in 66.7% of the patients. Excellent outcome can be achieved by radical exclusion of the abscess cavity and viable pulmonary autograft or stentless aortic root xenograft in patients with severe aortic annular destruction.
ABSTRACT
A 52-year-old man who had liver cirrhosis sufferred ruptured thoraco-abdominal aortic aneurysm. This patient was classified as having Child's class B liver cirrhosis preoperatively. The thoracoabdominal aorta was successfully replaced with reconstruction of the renal arteries, superior mesenteric artery, celiac artery, and 10th intercostal artery. Omentopexy was added. As persistent ascites continued postoperatively, peritoneovenous shunting was performed on the 29th postoperative day. Ascites disappeared and 20 days later the patient was discharged from hospital and has been well for two years.
ABSTRACT
A 71-year-old woman who had Takayasu's disease underwent Y-grafting, bypass grafting between the abdominal aorta and left renal artery with 8mm ePTFE graft and right nephrectomy for infrarenal abdominal aortic aneurysm and renovascular hypertension (RVH). Four years after the first operation, the bypass graft became occluded and hypertension was exacerbated. Magnetic resonance angiography revealed that the left renal artery was supplied by the collateral arteries. We performed replacement of the thoracoabdominal aorta and reconstruction of the left renal artery using the saphenous vein. Postoperatively serum creatinine level decreased and hypertension was controllable. She was discharged from the hospital and has been well for three years.
ABSTRACT
A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded <i>Bacteroides fragilis</i>. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by <i>Bacteroides fragilis</i>, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.
ABSTRACT
Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to <i>Salmonella</i> infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with <i>Salmonella</i> infection had bacteremia. The incidence of bacteremia in patients with <i>Salmonella</i> infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including <i>in situ</i> reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to <i>Salmonella</i> infection.
ABSTRACT
Three cases of aortic arch aneurysm complicated by aberrant right subclavian artery (ARSA) are reported. Two patients underwent emergent operations with diagnosis of a Stanford type A acute dissection and a ruptured distal arch aneurysm. The third patient underwent an elective operation under a diagnosis of distal arch aneurysm and right subclavian artery aneurysm. In all cases, deep hypothermic circulatory arrest with retrograde cerebral perfusion through median sternotomy was applied. The first patient with acute aortic dissection underwent total arch replacement and elephant trunk installation into the descending aorta. No ARSA was recognized. The other 2 patients underwent distal arch replacement with reconstruction of bilateral subclavian arteries. The <i>in-situ</i> reconstruction of the ARSA was performed in one patient and bypass grafting from the ascending aorta was done in the other patient. There were 2 hospital deaths. The postoperative angiogram of the first patient showed that the ARSA was occluded. One other patient needed a tracheostomy because of pulmonary complications and he died of asphyxia. The last patient died of esophageal perforation secondary to pressure necrosis.
ABSTRACT
Two cases of ruptured abdominal aortic aneurysm (AAA) treated with retroperitoneal approach are presented. Case 1 was a 73-year-old man with an infrarenal AAA of 44mm in diameter, and case 2 was a 73-year-old man with a 54mm pseudoaneurysm after graft replacement for AAA. Both patients had a history of previous laparotomy and their aneurysms had ruptured into only the right retroperitoneal space. A left retroperitoneal approach permitted wide and rapid exposure of the aorta with minimal damage to the intestines and respiratory function. Their postoperative courses were uneventful.
ABSTRACT
Arterial reconstructions for iliac artery obstruction (IAO) were performed in 81 patients (70 males and 11 females) with arteriosclerosis obliterans (80) and thromboangiitis obliterans (1) from January 1979 to January 1991. Ages ranged from 36 to 79 with a median age of 63.4. Aortofemoral bypass (AF-B) was performed in 46 cases (including 21 Y graft patients), thromboendarterectomy (TEA) in 11, femoro-femoral cross-over bypass (FF-B) in 26 and axillo-femoral bypass (AXF-B) in 2. No patients in the AF-B, TEA or AXF-B group showed postoperative early occlusion, while two in the FF-B group had early occlusion. The bypass flow measured intra-operatively using an electro-magnetic flowmeter was 50-1, 100 (average 382) ml/min in the AF-B, 190-500 (331) ml/min in the TEA, 90-650 (219) ml/min in the FF-B, and 200ml/min in the AXF-B group. Two patients died; one from ischemic colitis and the other from myonephropathic metabolic syndrome. The long-term cumulative patency rates at 1, 2 and 5 years were 100, 96, and 96% in the AF-B, 100, 100, and 100% in the TEA, and 90, 84, 63% in the FF-B group, respectively. The two AXF-B cases had good patency one year and three years postoperatively. AF-B should be recommended for aorto-iliac obstruction even in high risk patients as long as severe heart disease is absent, because of the long-term patency rate. An additional bypass to the popliteal region should be performed, if bypass flow to the distal region is low.
ABSTRACT
Two patients with an aorto-iliac arteriovenous fistula as a complication of abdominal aortic aneurysms were presented. Both patients showed pulsating abdominal mass, and swelling of unilateral leg. The fistula was preoperatively diagnosed in one and in another it was suspected intraoperatively by careful palpation of continuous thrill on the aneurysm. Successful surgical management was accomplished in both patients. Awareness of this clinical entities is necessary to manage this rare complication in abdominal aortic aneurysm surgery.
ABSTRACT
Rupture of the posterior wall of the left ventricle is rare but it is one of the fatal complications which can follow mitral valve replacement (MVR). Of 216 MVR patients, including 51 who had double valve replacements, we have had four patients (1.9%) with this complication. The rupture occurred on the table in one patient and about 40 to 90min after entering ICU in the others. All the ruptures were repaired under cardiopulmonary bypass and cardioplegic arrest. The site of rupture was type I in two cases and type II in the other two. Two patients expired. One patient who had been repaired in the operating room died from multiple organ failure after a stormy course of two week's duration, and one who had been repaired in ICU died from uncontrollable hemorrhage. In the remaining two patients, one with a type I and one with a type II rupture, successful treatment in ICU was achieved by suturing an equine pericardial patch to the normal endocardium and mitral ring over the entire area of laceration through endocardial site after removal of the valve prosthesis in the first place, and then wrapping the area of epicardial laceration with another equine patch. In order to reduce mortality in patients with left ventricular rupture, repair from inside of the heart using an equine patch described above was very effective, and the preparation to perform the operation immediately after the onset of rupture in ICU is an important consideration as well.