[Celiac Artery Bypass Grafting from the Ascending Aorta Following Aortic Repair for Treatment of Stanford Type A Acute Aortic Dissection Complicated by Abdominal Malperfusion:Report of a Case].

A 73-year-old woman presented with sudden chest and back pain. Computed tomography (CT) revealed Stanford type A acute aortic dissection complicated by occlusion of the celiac artery and stenosis of the superior mesenteric artery. Because there was no clear sign of critical abdominal organ ischemia before surgery, central repair was performed first. Then, after cardiopulmonary bypass, laparotomy was performed to check the blood flow in the abdominal organs. Malperfusion of the celiac artery remained. We therefore made an ascending aorta-common hepatic artery bypass using a great saphenous vein graft. Postoperatively, the patient was saved from irreversible abdominal malperfusion, however, her condition was complicated by paraparesis due to spinal cord ischemia. After a long period of rehabilitation, she was transferred to another hospital for rehabilitation. She is currently doing well at 15 months after treatment.

Thromboaspiration for Iatrogenic Thrombotic Occlusion of the Superior Mesenteric Artery during Endovascular Treatment of Pancreaticoduodenal Artery Aneurysm and Celiac Artery Occlusion.

Herein, we present a case of superior mesenteric artery (SMA) thrombus as a complication of stent placement for celiac stenosis and coil packing of a pancreaticoduodenal artery aneurysm. The SMA thrombus was likely caused by thromboembolism from the guiding sheath in the SMA without a continuous heparin flush. It was promptly treated with aspiration thrombectomy, and there was no mesenteric ischemia. To avoid thromboembolic complications, periprocedural prophylactic antithrombotic therapy should also have been performed because a complex procedure involving the pull-through technique was performed.

[Acute Leaflet Arrest in St. Jude Medical Regent Mechanical Aortic Valve;Report of a Case].

A 61-year-old woman was diagnosed with combined valvular disease and atrial fibrillation, and was admitted for surgery. We performed double valve replacement, tricuspid annuloplasty and maze operation. At the operation, a 19 mm St. Jude Medical Regent valve was implanted with non-everting mattress sutures at the aortic supra-annular position after mitral valve replacement. Although pulling down of the prosthesis into the aortic annulus was easy, the leaflets were unable to open at all in a movability test. After removing several stitches on the mitral side of the hinges, the subvalvular tissue was seen bulging into the hinge, hindering the free movement. The prosthesis was removed and replaced with a 17 mm Regent valve by the same technique. The patient's postoperative course was uneventful. We suggest it is necessary to pay special attention to the structural characteristics of the prosthesis.

Determination of oxidative stress and cardiac dysfunction after ischemia/reperfusion injury in isolated rat hearts.

BACKGROUND: Oxidative stress due to reactive oxygen species (ROS) is thought to play a considerable role in ischemia/reperfusion (I/R) injury that impairs cardiac function. The present study examined oxidative damage in I/R injury and investigated the correlation between oxidative stress and impaired cardiac function after I/R injury of the isolated rat heart. METHODS: Hearts isolated from male Sprague-Dawley rats were mounted on a Langendorff apparatus. Hearts arrested using St. Thomas cardioplegic solution and then they were reperfused. The hearts were divided into three groups depending on the frequency (0-2) of I/R. After I/R, left ventricular developed pressure (LVDP), left ventricular end-diastolic pressure (LVEDP), positive maximum left ventricular developing pressure (max LV dP/dt) and coronary flow (CF) were measured. Creatine kinase (CK) was measured in the coronary effluent and 8-hydroxy-2'deoxyguanosine (8OHdG), a marker of oxidative DNA damage, was measured. Adenosine triphosphate (ATP) was measured from frozen myocardial tissue after experiment. RESULTS: We immunohistochemically demonstrated and quantified levels of 8-OHdG after I/R injury of the heart. The frequency of I/R injury and cardiac dysfunction significantly and negatively correlated. The ATP products were similar among the three groups. The incidence of ventricular arrhythmias was not by affected oxidative stress. CONCLUSION: The frequency of I/R injury had more of an effect on 8-OHdG products and on impaired cardiac function with less myocyte damage than ischemic duration within 30 minutes of ischemia.

Repeat Operation for Pseudoaneurysm of Left Ventricular Outflow in a Patient with Concomitant Takayasu's Arteritis and Marfan Syndrome.

We describe concomitant Marfan syndrome and Takayasu's arteritis complicating a pseudoaneurysm of the left ventricular outflow that developed after aortic root reconstruction. A patient was admitted with a high fever four months after initial root reconstruction that included valve sparing (reimplantation) as well as coronary artery reconstruction using a Carrel's button technique. Computed tomography revealed a pseudoaneurysm at the posterior side of the aortic root. We applied a modified Bentall procedure including coronary artery reconstruction using the Piehler technique. Pathological assessment of a specimen of the aorta revealed no central medial necrosis, but significant lymphocytic infiltration and thick fibrous adventitia indicating Takayasu's arteritis. This case was unique in terms of having simultaneous Takayasu's arteritis and cardiovascular manifestations of Marfan syndrome that were surgically treated.

Total arch replacement using bilateral axillary antegrade selective cerebral perfusion.

OBJECTIVE: The prevention of cerebral injury is an important consideration during the repair of an aortic arch aneurysm, and this is a major goal of cerebral protection techniques. We describe extended thoracic aortic aneurysms treated by use of our current surgical strategy. PATIENTS AND METHODS: From January 2001 to June 2008, a total of 17 patients (12 men and 5 women; mean age 67.3 ± 7.3 yrs) underwent total arch replacement using bilateral axillary arterial perfusion. Six and 11 had nondissecting and dissecting aneurysms, respectively. Four patients (23.5%) with an impending ruptured aneurysm of the arch aorta or acute type A dissection underwent emergency surgery. We used bilateral axillary arteries for systemic as well as selective cerebral perfusion during the procedures. RESULTS: One patient died in the hospital (mortality rate, 5.9%) because of multiple organ failure. Mechanical ventilation was required after surgery for 4.6 ± 3.1 days. Permanent neurological dysfunction did not arise in this series. Although prolonged mechanical ventilation support was necessary, all patients recovered uneventfully from the procedures. CONCLUSION: We consider that median sternotomy, along with the left anterolateral thoracotomy approach and perfusion from the bilateral axillary arteries, illustrates the safety of the method. Moreover, our results suggested that perfusion from the bilateral axillary arteries can help to prevent cerebral damage.

Total arch replacement with associated anomaly of the left vertebral artery.

We describe total arch replacement after ascending aortic replacement for acute type II dissecting aneurysm with associated anomaly of the left vertebral artery. A female patient was recommended at 10 years of age after the initial operation because of an enlargement of the distal ascending aorta. Magnetic resonance angiography revealed an isolated left vertebral artery that arises distal to the left subclavian artery. Total arch replacement was proceeding using selective cerebral perfusion. The isolated artery was reconstructed with a saphenous vein graft interposed between the native left vertebral artery and the side of the graft branch anastomosed to the left subclavian artery. The patient recovered uneventfully after extensive surgical replacement of the thoracic aorta and remains asymptomatic at 1 year after the procedure. To prevent possible neurological complications, we find it critical to assess vascularization in this region prior to conducting surgical procedure. Careful examination and correct identification of the vessels are essential to avoid major complications.

Post-sternotomy hemorrhage due to left internal thoracic artery pseudoaneurysm.

We describe a case of pseudoaneurysm of the internal thoracic artery, which was probably caused by infection. Four weeks after aortic valve replacement and coronary artery bypass surgery, an 84-year-old woman suddenly developed painful sternal instability and hypotension, with active hemorrhage from a left parasternal swelling. Selective arteriography revealed a pseudoaneurysm of the left internal thoracic artery. It was surgically excised, and the patient recovered uneventfully.

Total arch replacement for distal enlargement after ascending aortic replacement for acute type A aortic dissection.

OBJECTIVE: Distal reoperations for aortic dissection are associated with high morbidity rates. We describe distal aortic enlargement that was treated using our surgical strategy. PATIENTS AND METHODS: From January 1997 to April 2008, 63 patients underwent ascending aortic replacement for acute type A aortic dissection. Four patients (7.4%; 3 males, 1 female; mean age, 67.8 +/- 4.6 years) required reoperation for distal enlargement after long-term follow-up. Individual 5- and 10-year rates of those remaining free of reoperation after the initial procedure were 94.9% and 83.0%, respectively. At reoperation, a median sternotomy with left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. RESULTS: Mechanical ventilation was required after surgery for 3.0 +/- 1.4 days. No new phrenic or left recurrent laryngeal nerve palsy or permanent neurological dysfunction occurred in this series. Although the surgical duration and relative mechanical circulation time were significantly elongated, all patients recovered uneventfully. CONCLUSION: We postulate that the surgical principle involved in treating aortic dissection is a resection of the aortic segment containing the initial intimal tear and graft replacement, especially in acute dissection. Our results showed that total arch replacement through a median sternotomy and left anterolateral thoracotomy seem to be helpful for extended replacement of the thoracic aorta, as well as in the distal reoperation for dissecting type A. Moreover, our results suggested that perfusion from bilateral axillary arteries is useful to prevent cerebral damage.

Aortic replacement via median sternotomy with left anterolateral thoracotomy.

Prevention of cerebral injury is an important consideration during repair of aortic arch aneurysm, and the major goal of cerebral protection techniques. We describe our surgical strategy for treatment of extended thoracic aortic aneurysms. Between January 2001 and June 2008, 17 men and 6 women, with a mean age of 67.9 +/- 8.3 years, underwent total replacement of the arch and descending aorta. Six (26.1%) patients required emergency surgery. A median sternotomy with a left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. Two (8.7%) patients died in hospital. Prolonged mechanical ventilation was required for 7.3 +/- 8.4 days after surgery in 17 patients who all recovered uneventfully. Permanent neurological dysfunction developed in 1 (4.3%) patient who died of sepsis 2 years after the operation. Our results suggest that total arch replacement through a median sternotomy plus a left anterolateral thoracotomy is helpful for extended replacement of the thoracic aorta as well as distal reoperation for dissecting type A aortic aneurysm. Perfusion via bilateral axillary arteries may improve cerebral protection.

A three-decade experience of radical open endvenectomy with pericardial patch graft for correction of Budd-Chiari syndrome.

BACKGROUND: We previously reported the value of our operative procedure for Budd-Chiari syndrome (BCS) that comprised reconstruction of the occluded or severely stenosed inferior vena cava (IVC) using an autologous pericardium patch and reopening as many occluded hepatic veins as possible. Here, we present the long-term durability and efficacy of the autologous pericardium patch for reconstruction of the IVC in BCS. METHODS: We retrospectively analyzed a series of 53 consecutive patients (mean age, 48.4 +/- 12.8 years; range, 24-76 years; 34 men) who underwent surgical treatment for BCS at our institution from 1979 to 2008. Patency of the IVC and hepatic veins was examined by venography at discharge. Patients attended an outpatient clinic every 1 or 2 months for follow-up. The reconstructed IVC was evaluated by enhanced computed tomography every 1 or 2 years. RESULTS: Two in-hospital (operative mortality, 3.7%) and 15 late deaths occurred. During a mean follow-up of 7.6 +/- 6.5 years (range, 0.08-24.1 years), the reconstructed IVC became totally obstructed in three patients, of whom two underwent reoperation, and severely stenosed in two patients, who required percutaneous transvenous balloon venoplasty (PTV). The 5- and 10-year patency rates without reoperation or PTV for the reconstructed IVC were 90.5% and 84.3%, respectively. The cumulative 5- and 10-year survival rates were 89.8% and 70.7%, respectively. CONCLUSION: The autologous pericardium patch is effective and durable for reconstructing a diseased IVC in BCS.

Unruptured, isolated giant aneurysm of the sinus of valsalva resulting from medial mucoid degeneration.

We report a quite rare case of unruptured, isolated giant aneurysm of the sinus of Valsalva resulting from medial mucoid degeneration in a young adult woman. A 29-year-old Japanese female diagnosed as having an aneurysm of the sinus of Valsalva and severe aortic regurgitation with no clinical findings of Marfan's syndrome or Ehlers-Danlos syndrome. A modified Bentall's operation was performed successfully, and she was discharged with no complications. A pathological examination revealed marked medial mucoid degeneration of the aneurismal wall. In the literature, most giant aneurysms resulting from mucoid degeneration were found in African young adult females. In this case, there was much mucoid degeneration in the media with no focal destruction of elastic fibers, which was distinct from cystic medial necrosis in Marfan's syndrome. A careful follow-up will be required to detect any other aneurysmal formation in the future.

Intraoperative retrograde type I aortic dissection in a patient with chronic type IIIb dissecting aneurysm.

Iatrogenic acute aortic dissection of the ascending aorta during cardiac surgery is a rare but potentially fatal complication. We describe the emergency repair of iatrogenic acute aortic dissection of the ascending aorta during distal arch replacement in a patient with a chronic type IIIb dissecting aneurysm. We scheduled distal arch and descending aortic aneurysm repair through a left anterolateral thoracotomy with a femoro-femoral bypass. While trimming the proximal suture line, retrograde aortic dissection occurred from the cross-clamped site to the aortic root. Transesophageal echocardiography revealed aortic dissection at the ascending aorta. As soon as the additional median sternotomy was established, the ascending aorta was transected and antegrade selective cerebral perfusion was applied without waiting for further cooling. Total arch replacement with descending aortic and root replacements then proceeded. The patient recovered uneventfully after extensive surgical replacement of the thoracic aorta and remains asymptomatic at two years after the procedure. To prevent possible neurological complications, this patient was managed by selective antegrade cerebral perfusion at 31 degrees C because we could not afford to wait for the induction of deep hypothermia. Successful management of iatrogenic acute aortic dissection depends on immediate recognition and the appropriate choice of surgical repair.

Delayed response of transcranial myogenic motor-evoked potential monitoring to spinal cord ischemia during repair surgery for descending thoracic aortic aneurysm.

The efficacy of transcranial myogenic motor-evoked potential (tc-MEP) monitoring during thoracic aortic surgery has been the subject of some reports, because tc-MEP monitoring can rapidly reflect changes in spinal cord blood flow during thoracic aortic cross-clamping. In this article, we present a case in which delayed loss of tc-MEP signals was observed after cross-clamping of the descending thoracic aorta. We must be aware that tc-MEPs recorded from the lower extremities can fail to provide rapid detection of spinal cord ischemia in the upper thoracic level after cross-clamping of the descending thoracic aorta.

Infected thoracoabdominal aortic aneurysms including the major abdominal branches in 4 cases.

We present four cases of infected thoracoabdominal aortic aneurysm (TAAA), including abdominal branches that underwent surgical repair. The mean age of patients at the time of operation was 61+/-18 (range: 39-83) years. The extent of the aneurysm was Crawford type III in 1 case and type IV in the other 3. They all underwent an emergency or urgent operation, which consisted of a debridement of the infected tissue, in situ four-branched Dacron graft replacement, and iodine gauze packing for 48 h followed by omental wrapping of the graft. To prevent postoperative spinal ischemia, intercostal and lumbar arteries were reimplanted under motor-evoked potential (1.25 pairs per patient). There was one (25%) hospital death, but postoperative graft infection did not occur in these present cases during a mean follow-up period of 15+/-43 (1-96) months. Antibiotics were administered intravenously for 8 weeks after the operation, then continued orally for a lifelong period. Postoperatively, paraplegia occurred in one (25%) patient. Our strategy for infected TAAA including major abdominal branches may prevent postoperative graft infection.

Cardioprotective effects of tetrahydrobiopterin in cold heart preservation after cardiac arrest.

BACKGROUND: It has recently been shown that tetrahydrobiopterin (BH4), an essential cofactor of nitric oxide synthase (NOS), reduces ischemia-reperfusion myocardial injury. The aim of this study was to determine if supplementation with BH4 after cardiac arrest followed by cold heart preservation would exert a cardioprotective effect against ischemia-reperfusion injury. MATERIALS AND METHODS: Isolated perfused rat hearts were subjected to 4 degrees C cold ischemia and reperfusion. Hearts were treated with cold cardioplegic solution with or without BH4 just before ischemia and during the first 5 min of reperfusion period. Effects of BH4 on left ventricular function, myocardial contents of high-energy phosphates, and nitrite plus nitrate were measured in the perfusate, before ischemia and after reperfusion. Moreover, the effect of BH4 on the cold-heart preservation followed by normothermic (37 degrees C) ischemia was determined. RESULTS: BH4 improved the contractile and metabolic abnormalities in reperfused cold preserved hearts that were subjected to normothermic ischemia. Furthermore, BH4 significantly alleviated ischemic contracture during ischemia, and restored the diminished perfusate levels of nitrite plus nitrate after reperfusion. CONCLUSION: These results demonstrated that BH4 reduces ischemia-reperfusion injury in cold heart preservation. The cardioprotective effect of BH4 implies that BH4 could be a novel and effective therapeutic option in the preservation treatment of donor heart after cardiac arrest.

Improvement of liver function after surgery for Budd-Chiari syndrome.

PURPOSE: We evaluated the relationship between liver histology and postoperative improvement of liver function after surgery for Budd-Chiari syndrome (BCS). METHODS: Over a period of 23 years, we operated on 46 patients with BCS by reconstructing the occluded inferior vena cava (IVC) and reopening as many occluded hepatic veins as possible. We divided the patients into a liver cirrhosis group (group I, n = 30) and a hepatic fibrosis or liver congestion group (group II, n = 16), and compared the ages, duration of illness, preoperative liver function, changes in liver function, and changes in esophageal varices (EV). RESULTS: There were no hospital deaths. In group I the patients were older, and the duration of illness was longer. The group I patients also had a lower thrombotest percentage and a higher serum ammonia. The indocyanine green clearance (ICG) test showed more remarkable improvement in liver function in group II. The rate of disappearance of EV was also higher in group II. CONCLUSION: Surgery during the early stage of BCS is important in improving postoperative liver function.

Malignant fibrous histiocytoma of the heart complicated by factor XI deficiency in a Jehovah's Witness patient.

We describe a 16-year-old girl with malignant fibrous histiocytoma (MFH) of the heart complicated by factor XI deficiency. The preoperative diagnosis was left atrial myxoma. We decided to perform the operation owing to a normal bleeding time. Operative findings suggested a malignant tumor. The patient was a Jehovah's Witness, and extensive excision was not performed because blood transfusion was not allowed. We resected as much of the tumor and left atrial appendage as possible. The pathologic diagnosis was MFH. Excessive bleeding was not observed during the operation. Bleeding time helps to determine whether a surgical procedure is indicated in patients with factor XI deficiency.

Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery.

OBJECTIVE: We investigated the benefit of diaphragmatic plication for weaning from mechanical ventilation in these adult patients. PATIENTS AND METHODS: Four patients underwent diaphragmatic plication for difficulty of weaning from mechanical ventilation due to diaphragmatic paralysis. They were all men with an average age of 70.5 +/- 6.3 years. Three of the patients had undergone cardiac surgeries for coronary artery bypass grafting and one patient ascending aortic replacement for pseudoaneurysm after coronary revascularization. Right diaphragmatic plication (muscle sparing procedure) was performed between 30 to 61 days after cardiac surgery. RESULTS: The mean forced tidal volume improved dramatically from 216 to 415 ml after plication in all patients, and it was possible to discontinue mechanical ventilation from 2 to 12 days after plication. One patient with obstructive respiratory dysfunction died from aspiration pneumonia 15 days after plication. However, postoperative tidal volume in this patient improved to 420 ml and he was able to be weaned from ventilatory support five days after plication. The other three patients were discharged between 26 to 58 days after plication and continue to do well without symptoms. CONCLUSION: Diaphragmatic plication is a useful procedure for treatment of diaphragmatic paralysis in adults as well in children.

Type B dissection complicated with subacute visceral ischemia.

A 63-year old man presented with back pain and abdominal pain that worsened after eating. Contrast-enhanced computed tomography revealed type B aortic dissection. Arteriography 20 days after dissection revealed celiac trunk stenosis and the superior mesenteric artery did not arise from the true lumen. Saphenous vein bypass grafting from the right common iliac artery to the superior mesenteric and gastroduodenal arteries was performed. The postoperative course was uneventful and the abdominal symptoms completely disappeared.