Hemolytic Anemia Associated with a Teflon Felt Strip on a Proximal Anastomotic Site for Aortic Replacement in a Patient with Aortic Dissection / 日本心臓血管外科学会雑誌

A 61-year-old man was referred to our hospital for treatment of hemolytic anemia after ascending aortic replacement aortic dissection. Cine mode magnetic resonance imaging (MRI) showed stenosis at the proximal anastomostic site of a Teflon strip. We diagnosed hemolytic anemia induced by collision of red blood cells on the inverted felt strip. Conservative therapy with Sarpogrelate and β-blockers was effective to treat his hemolytic anemia. However, 7 years later he was re-admitted because of infective endocarditis at the aortic valve, and underwent aortic root replacement. Intraoperative findings showed a stiff and inverted Teflon felt strip causing stenosis of the proximal anastomosis. Hemolytic anemia should be considered a rare complication of using a Teflon felt strip to reinforce anastomosis for acute aortic dissection.

Leaflet Extension Aortic Valvuloplasty and Mitral Valve Replacement for Congenital Bicuspid Aortic Stenosis with Severe Mitral Regurgitation in a Child / 日本心臓血管外科学会雑誌

A baby girl with a low birth weight was given a diagnosis of congenital bicuspid aortic stenosis and mitral valve prolapse. At the age of 40 days, she underwent balloon aortic valvotomy, but significant aortic regurgitation appeared afterwards. Another surgical intervention became necessary by the age of 20 months (weight, 5.7 kg), because of intractable heart failure mostly caused by exacerbated mitral regurgitation. We performed a leaflet extension valvuloplasty for the small bicuspid aortic valve using an autologous pericardium treated by glutaraldehyde. The mitral valve was replaced with an ATS-16AP valve. Although her postoperative course was complicated with mitral paravalvular leakage and poor left ventricular function, she was discharged from hospital 6 months post operatevely. Leaflet extension valvuloplasty is a surgical option for infants with a small aortic annulus, but the procedure could be the only solution in cases when Konno or Ross techniques are not suitable.

Surgical Correction for Congenital Valvular and Supravalvular Aortic Stenosis Associated with Coronary Ostial Stenosis in a Child / 日本心臓血管外科学会雑誌

Supravalvular aortic stenosis is a rare obstructive lesion of the left ventricular outflow tract localized at the level of sinotubular junction. It has been recognized that supravalvular stenosis may occur as a part of Williams syndrome and is sometimes complicated by obstruction of the left main coronary artery. We successfully performed single patch augmentation for supravalvular aortic stenosis and left coronary ostial stenosis with concomitant aortic valvotomy in a child without Williams syndrome. The patient had been followed as congenital bicuspid aortic valvular and supravalvular stenosis. At the age of 3 years, cardiac catheterization revealed an increased pressure gradient of 90mmHg at the left ventricular outflow and newly developed ostial stenosis of the left coronary artery. An oblique incision on the ascending aorta was made above the sinotubular junction and extended leftward onto the left main coronary artery, and this incision opened the fibrous ridge at the left coronary artery. After commissurotomy for the bicuspid valve, both the supravalvular and ostial stenosis were augmented with a single autologous pericardial patch treated by glutaraldehyde. The pressure gradient was significantly reduced and the ischemic left ventricular dysfunction was eliminated.

Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy in a Child / 日本心臓血管外科学会雑誌

A 6-year-old boy who had been found to have hypertrophic obstructive cardiomyopathy presented with severely limited symptoms of heart failure due to progressive left ventricular outflow obstruction. Cardiac catheterization revealed the peak systolic pressure gradient of 87mmHg at left ventricular outflow, and systolic anterior motion of the anterior mitral leaflet with concomitant mitral regurgitation was observed by echocardiography. Transaortic septal myectomy was performed using transesophageal echocardiography guidance before, during and after surgery. Although the patient needed permanent pacemaker implantation for postoperative complete heart block, the procedure reduced the left ventricular outflow obstruction and relieved his symptoms.

Damus-Kaye-Stansel Anastomosis for Rapid Progression of Subaortic Stenosis after Pulmonary Artery Banding in a Single Ventricle Infant with Aortic Arch Hypoplasia / 日本心臓血管外科学会雑誌

A cyanotic baby boy was given a diagnosis of single right ventricle, double outlet right ventricle, hypoplastic aortic arch, mitral atresia, atrial septal defect and pulmonary-ductus-descending aorta trunk. On day 4, extended aortic arch anastomosis and pulmonary artery banding were undertaken. At age 70 days, severe cyanosis and respiratory distress appeared and advanced rapidly. Angiography revealed critical subaortic stenosis and pulmonary hypertension, and the patient required urgent Damus-Kaye-Stansel anastomosis with concomitant right modified Blalock-Taussig shunt. Patients with single ventricle and hypoplastic aortic arch are a high-risk subgroup of progressive subaortic stenosis after initial pulmonary artery banding, and therefore need careful observation and may require early relief of subaortic stenosis.

Salvage Therapy with Non-Heparinized Extracorporeal Life Support for Massive Lung Hemorrhage after Pulmonary Thromboembolectomy / 日本心臓血管外科学会雑誌

Lung hemorrhage associated with pulmonary reperfusion injury is a rare but lethal condition. We presented a case salvaged by non-heparinized extracorporeal life support for massive lung hemorrhage after pulmonary thromboembolectomy. Sub-acute pulmonary thromboembolism with a floating right atrial thrombus was diagnosed in 63-year-old woman by computed tomography and echocardiography. An emergency pulmonary thromboembolectomy was performed using cardiopulmonary bypass and moderate hypothermia. Immediately after reperfusion, extraordinary lung hemorrhage occurred and continued. We decided to take over the standard cardiopulmonary bypass with a non-heparinized extracorporeal life support system. Fortunately, hemostasis of the lung hemorrhage was completely secured within 12h, and the extracorporeal life support was terminated at 20h after the surgery. The patient was extubated at 48h after the surgery, and was discharged after the insertion of an inferior vena cava filter for a floating deep venous thrombus. Although the necessity, efficacy and risk of the non-heparinized extracorporeal life support should be clarified, we conclude that it could be the treatment of choice for life threatening lung hemorrhage associated with pulmonary reperfusion injury.

Profound Hypothermia-Induced Platelet Dysfunction during Heparinized Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

There is an impression among cardiothoracic surgeons that the technique of profound hypothermic circulatory arrest (PHCA) is associated with an increased bleeding tendency compared to conventional bypass surgery. In addition to the recognized factors contributing to the hemorrhagic tendency seen in moderate hypothermic cardiopulmonary bypass (CPB), it is likely that the lower temperature utilized in PHCA may exacerbate platelet dysfunction. In this report, platelet counts and functions at the same cardiopulmonary bypass time were compared in human PHCA surgery (hypothermia group, <i>n</i>=16) and moderate hypothermic cardiopulmonary bypass surgery (control group, <i>n</i>=20). Mean platelet count corrected by hematocrit in the hypothermia group at 2h of CPB was significantly lower than in the control group (3.7×10⁴μl vs. 11.4×10⁴/μl, <i>p</i><0.0001). In the hypothermia group, there were significant increases in the percentage of GMP-140 (P-selectin)-positive platelets (11.8% vs. 8.3%, <i>p</i>=0.0091) at 1h of CPB, and also in microparticles (24.8% vs. 10.5%, <i>p</i><0.0001) and aggregated platelets (3.4% vs. 1.4%, <i>p</i>=0.0058) at 2h of CPB. Profound hypothermic circulatory arrest used in surgery for aortic arch aneurysm or dissection may cause irreversible platelet dysfunction and contribute to hemorrhagic tendency during the surgery. To minimize platelet dysfunction during CPB, the lowest blood temperature should be maintained above 15°C.

Subepicardial Aneurysm: A Case Report / 日本心臓血管外科学会雑誌

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.

Major Hemorrhage from the Lung after Surgery of Congenital Heart Defects: Catastrophic Complication / 日本心臓血管外科学会雑誌

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

Perioperative Anticoagulation Therapy for Patient with Abdominal Aortic Aneurysm after Heart Valve Surgery / 日本心臓血管外科学会雑誌

Under scheduled anticoagulation therapy, surgery for abdominal aortic aneurysm was performed in 4 patients who had undergone heart valve surgery and implantation of a mechanical prosthesis. Warfarin and antiplatelet agents were prescribed in all cases preoperatively. Antiplatelet agents were discontinued from seven to 10 days before operation. Warfarin was stopped from two to three days before operation and heparin (200IU/kg/day) was administered by continuous intravenous infusion to produce an activated clotting time of around 150 seconds. Bolus intravenous heparin of 3, 000 IU was added before aortic crossclamp. Oral anticoagulants were resumed from the beginning of oral intake, and heparin was stopped when the prothrombin time reached therapeutic levels (% PT=40%). In three patients perioperative courses were uneventful. Intraperitoneal hemorrhage occurred in one patient who simultaneously underwent cholecystectomy and aneurysmectomy with Y-grafting. He required blood transfusion and interruption of anticoagulation. Brain thromboembolism occurred in this patient 26 days after the operation. We believe that scheduled anticoagulation for the operation of abdominal aortic aneurysm is safe and useful in patients with prior prosthetic heart valve surgery. However, the coexistence of coagulopathy requires more intensive anticoagulation therapy.

Surgical Treatment for Airway Obstructions Associated with Congenital Heart Disease / 日本心臓血管外科学会雑誌

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

Investigation on Improvement of Peripheral Circulation by Continuous Use of Prostaglandin E1 during Open Heart Surgery. Evaluation with Peripheral Blood Flow by Laser Doppler Flowmeter and Temperature Difference between the Periphery and Core / 日本心臓血管外科学会雑誌

Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.

A Fourteen-Day-Old Neonate with Congenital Aortic Valve Stenosis Successfully Treated with Open Valvular Commissurotomy / 日本心臓血管外科学会雑誌

A thirteen-day-old neonate was admitted because of systolic heart murmur, tachycardia, tachypnea and sucking weakness. The chest X-ray film demonstrated remarkable cardiomegaly and pulmonary congestion. Echocardiography detected marked thickening and stenosis of the aortic valve, and left ventricular dysfunction (EF=10%). The pressure gradient between left ventricle and ascending aorta was presumed 130mmHg with pulsed Doppler echocardiography, Since he did not respond to conservative treatment, an emergency open aortic valvular commissurotomy under cardiopulmonary bypass was performed the day after admission. We made incisions of 1mm in the left side and 0.5mm in the right side commissure of the adherent bicuspid aortic valve. After the procedure, left ventricular function improved (EF=57%), and the pressure gradient was reduced to 62mmHg. He showed good recover from the congestive heart failure. There are few reports about operative treatment of congenital aortic valve stenosis in neonates. This is considered to be the third youngest successful operative case of open aortic valvular commissurotomy in Japan.

A Case Report of Successful Surgical Treatment of High Aortic Occlusion with Acute Ischemia of Intrapelvic Organs and Bilateral Lower Extremities / 日本心臓血管外科学会雑誌

This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.

Causative Factors for Thrombi Formation in Mitral Stenosis / 日本心臓血管外科学会雑誌

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (<i>p</i><0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74<i>l</i>/min) compared with LAT(-) group (3.99±1.07<i>l</i>/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (<i>p</i><0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

Aorto-Renal Artery reconstruction for renvoascular Hypertension Due to takayasu's disease / 日本心臓血管外科学会雑誌

Thirty-nine years old woman had a severe renovascular hyper-tension with Takayasu's arteritis Her left renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) three times. Six months after the third PTA, the left renal artery was occluded, and left renal failure occurred. Aorto-renal bypass surgery with a prosthetic graft was performed. Blood pressure dropped to normal range, and left renal function began to recover. Although PTA is an effective method in the treatment of renovascular hypertension, an incidence of restenosis after PTA is higher in Takayasu's arteritis rather than atherosclerotic lesions. Five months after renal revascularization, hypertension recurred in this case. However the aorto-renal bypass graft was patent accompanied by no symptoms. This aorto-renal bypass surgery can be considered effective in this condition.

Surgical Repair of Atrial Septal Defect in Adult Patients / 日本心臓血管外科学会雑誌

Fifty-five adult patients with atrial septal defect (ASD) were surgically treated. In the preoperative study, 6 patients showed high pulmonary artery systolic pressure (>50mmHg). However, there was no linear relation between PAP and age, nor between <i>Q</i>_p/<i>Q</i>_s and PAP. As for the additional surgical procedures, MVR (1), MAP (1), TAP (3), OPC (2) were carried out with ASD closure in 7 patients. Post-operative evaluation with echocardiography revealed increase in the left ventricular chamber size, decrease in the severity of tricuspid regurgitation and same grade mitral regurgitation compaired with pre-operative level. From these data, the prediction of the atrioventricular valve regurgitation after ASD closure seemed to be difficult just from the preoperative evaluation, Transesophageal echocardiography was useful for the evaluation of residual atrioventricular valve regurgitation during operation in the cases of ASD with over II grade regurgitation preoperatively.