Search

虚血性の高度低左心機能 (心プールシンチで左室駆出率6.2%, 心エコーでLVDd=74mm, LVDs=71mm, %FS=10%) 症例に対し, 人工心肺を用いない心拍動下冠状動脈バイパス術を施行し, 良好な結果を得た1例を経験した. 症例は67歳, 男性で4年前に心筋梗塞を発症. 今回入院時の冠状動脈造影検査にて右冠状動脈の完全閉塞を含む重症3枝病変と診断. 通常の手術では人工心肺よりの離脱が困難となる可能性が高いと考え, 唯一心筋 viability が残されている右冠状動脈領域に心拍動下CABG (右胃大網動脈-右冠状動脈) を施行した. 術後心不全症状は著明に改善し, 軽快退院した. 自験例は欧米では心臓移植も考慮されるべき重症例と考えられ, 虚血性低左心機能に対する治療法として有用であると考えられた.

1982年3月より1993年1月の10年11か月の間に閉塞性動脈硬化症 (以下ASO) に対し当院で施行した腋窩-大腿動脈バイパス術は15例であった. 年齢は48歳から87歳, 平均71.2歳で全例男性であった. 術前, 全例が併存疾患を有していた. 3例が緊急手術であった. 待機手術12例のうち併存疾患のため2例の病院死がみられたが残る10例は軽快退院した. 退院例10例のうち併存疾患による遠隔期死亡4例, 不明の1例を除く生存例5例の観察期間は20～78か月, 平均47.6か月でグラフト開存率は100%であり, 全例日常生活を送っている. また, 稀な合併症としてグラフト周囲の seroma を経験した. 難治性の場合, グラフトの種類を換えることが有効であった. 腋窩-大腿動脈バイパス術は合併症を有する全身状態不良のASO患者に対し有用な術式である. 重症呼吸不全例などに対しては硬膜外麻酔と局所麻酔の併用で手術を行うことによりさらに侵襲を少なくすることが可能である.

[目的]胸部嚢状大動脈瘤に対する瘤切除パッチ形成術は,簡便な方法として施行されてきたが,術後長期での大動脈瘤発生の問題が指摘されている.今回当院における遠隔成績を検討した.[方法]1988年8月から2001年12月までに行われた,真性胸部嚢状大動脈瘤に対するパッチ形成術8例のうち,手術生存例7例の遠隔成績を追跡した.[結果]7例中6例が追跡可能であった.大動脈瘤の再拡大は3例で確認され2例に再手術を施行した.突然死を2例で認め,術後2年目に突然死した1例は,死体解剖にて吻合部の破裂を確認した.[結論]真性胸部嚢状大動脈瘤に対するパッチ形成術後には,高率に動脈瘤の再発を認めた.非常にhigh riskな症例や動脈硬化性でないものを除いて,原則的には大動脈全置換が選択されるべきと考えられた.

Giant sinus node artery aneurysms with a fistula into the left atrium are extremely rare. A 76-year old woman was admitted to our hospital for an abnormality on her chest X-ray. Coronary computed tomography (CT) angiogram revealed a giant coronary aneurysm with feeding arteries arising from the sinus node artery and the left circumflex artery. Additionally, the aneurysm had a fistula into the left atrium. The size of aneurysm was 70 × 50 mm. Coronary angiography showed contrast dye drained from the aneurysm to the left atrium through the fistula. Surgical treatment was performed. After feeding arteries were ligated, the aneurysm was opened under routine cardiopulmonary bypass. The diameter of the fistula entry was found to be 2 cm, and it was closed using a patch material. Since we were not able to identify the anatomical relationship of the fistula, mitral valve and pulmonary veins through the origin of the fistula, we used an additional right lateral left atriotomy approach. The aneurysmal wall was resected, and the cause of aneurysmal change was histopathologically diagnosed as atherosclerosis. The patient's postoperative course was uneventful, with a postoperative CT showing a complete exclusion of the aneurysm.

The prevalence of coronary artery disease in patients with aortic aneurysm is high. As an antecedent percutaneous coronary intervention with antiplatelet therapy may cause a rupture of aortic aneurysm, concomitant treatment for aortic arch aneurysm and coronary artery disease is recommended. We report a technique of a combined procedure of antegrade endovascular repair with aortic arch debranching and off-pump coronary artery bypass grafting. (J Card Surg 2012;27:518-520)

Surgeons should be aware of diaphragmatic hernia in obese patients who have undergone coronary artery bypass grafting (CABG) using a gastroepiploic artery graft (GEA), even if the antegastric route is utilized.We report a case of diaphragmatic hernia, which occurred 88 months after initial CABG. A 64-year-old obese man underwent surgical repair of a diaphragmatic hernia. At initial surgery, the diaphragm was incised vertically and re-sutured, leaving a route for GEA graft. Both the stomach and the lateral segment of the liver were dislocated in the pericardial space. The diaphragmatic defect was closed with a polytetrafluoroethylene patch.

In recent years, minimally invasive cardiac surgery has been developed. Thus far, only at our institute has port-access aortic valve replacement (PAVR) been performed in Japan. Herein we review our experiences with PAVR, and evaluate the surgical outcomes.Between May, 2007 and June, 2010, 37 cases of PAVR were performed. During the same period, 107 patients underwent conventional aortic valve replacement (CAVR) with midline sternotomy. Because we initially selected patients without high risk factors for PAVR, there were some differences in the preoperative demographic data between the CAVR and PAVR groups. Although cardiopulmonary bypass time and cross-clamp time were longer in the PAVR group (139 ± 28 vs. 113 ± 34 min; 97 ± 23 vs. 83 ± 24min), there were no significant differences in total operative time between both groups. With regard to the percentage of blood transfusion requirement, postoperative ventilation time, intensive care unit stay and hospital stay the PAVR group had significantly lower outcomes (11 vs. 90; 3.4 ± 1.9 h vs. 8.2 ± 16.3 h; 1.2 ± 0.6 days vs. 2.5 ± 1.7 days; 11.1 ± 4.3 days vs. 19.7 ± 7.8 days, respectively). There were no significant differences in mortality (1/37), and morbidity between both groups.PAVR a feasible treatment of choice for patients with aortic valve diseases complicated by various preoperative backgrounds.

1981年から1990年までに5例の胸腹部大動脈瘤 (TAA) 手術を施行した. 今回, 壁在血栓により総肝動脈閉塞をきたし, 腹部アンギーナ発作を伴ったTAAを経験した. 症例は, 58歳男性で約半年間不定の腹痛を繰り返し, 一過性に肝酵素の上昇を認めた. 血管造影等により総肝動脈閉塞をきたした胸腹部大動脈瘤と診断し, 遠心ポンプを用いた部分左心バイパス下に人工血管置換術を施行した. 総肝動脈, 上腸間膜動脈は Crawford 法にて再建した. 腹部アンギーナは比較的稀な疾患であるがTAAがその原因となっているものは非常にまれである. 手術に際しては完全に血行を再建する必要はないといわれており, 術前血管造影による正確な血流分布の把握が必要である.

A 54-year-old man underwent aortic repair for the infected thoracoabdominal aneurysm with a woven Dacron graft (Vascutek, Renfrewshire, Scotland) treated with gentian violet. Four months later, he complained of sudden back pain, resulting in preshock status. Computed tomographic scans showed massive hematoma around the Dacron graft, suggesting graft rupture. Initially, emergency thoracic endovascular aortic repair was performed, which was subsequently followed by open repair. The Dacron graft had a small hole, which was completely compatible with the site contacting with the rib. The graft rupture was considered due to its friction against the rib. We report on a rare event of mechanical Dacron graft rupture after the thoracoabdominal aortic replacement.

We present the technical details of en bloc resection and extended replacement of an infected aortic arch. A 74-year-old man underwent emergent surgery under a diagnosis of impending rupture of an infected aortic arch aneurysm. The patient’s chest was entered through a median sternotomy with a left thoracotomy at the fourth intercostal space. After dissection of the left phrenic and left recurrent nerves, the infected aortic arch was widely excised en bloc under circulatory arrest with selective cerebral perfusion. It was replaced with a rifampicin-bonded prosthetic graft. The prosthesis and anastomoses were covered with a harvested omental flap. Although an appropriate approach and supportive therapy are indispensable, en bloc resection of the infected tissue is an important technique when treating infected aortic aneurysms.

Endotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE.From November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006.PMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups.Intraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE.

Endovascular repair remains a challenge in the treatment of juxtarenal abdominal aortic aneurysms (AAAs); open surgery is now the treatment of choice. Because the proximal anastomosis involves a fragile aortic wall and renal ischemic time is correlated with postoperative renal dysfunction, simple and secure reinforcing of the suture line is indispensable in juxtarenal AAA repair. Our report describes the efficacy of prosthetic sleeve reinforcing (PSR) for this repair.From 2005 to 2009, 30 patients, including 4 with ruptured aneurysms, underwent juxtarenal AAA repair with PSR. We reviewed their in-hospital and midterm outcomes.Mean renal ischemic time was 26 ± 5.5 min. Mean hospital length of stay was 19 days; including 4 cases of ruptured juxtarenal AAA, there were no mortalities. Three patients with preoperative renal dysfunction, including 2 with aneurysmal rupture, required temporary renal replacement therapy. The overall survival rate was 93% (28/30). There was no case of postoperative graft-related complications, including anastomotic pseudoaneurysm and graft-enteric fistula.PSR enables secure and prompt proximal anastomosis, preventing postoperative morbidity and late graft-related complications. We conclude that PSR could be a valuable method for juxtarenal AAA repair.

A 40-year-old woman was admitted because of progressive dyspnea on exertion. Magnetic resonance imaging revealed an atrial septal defect and an abnormal membranous structure separating the left atrium into proximal and distal chambers. Surgical correction was performed by a minimally invasive surgical approach, i.e., port-access heart surgery, under the diagnosis of cor triatriatum (subtype of Lucas Schmidt IIIA1 or IB1) complicated with atrial septal defect. The postoperative course was uneventful, and she was discharged 12 days after surgery. This case is the first report of a surgical correction for cor triatriatum using the port-access technique.

A 42-year-old man suffering from massive aortic valve regurgitation with mild stenosis because of a bicuspid valve underwent surgery in May 2007. The surgical procedure was performed through a right anterolateral thoracotomy using the peripheral cannulation method. Cardiac arrest was achieved by direct aortic cross-clamping and selective cardioplegia delivery. The aortic valve was replaced with a bioprosthesis. The operation and aortic cross-clamping periods were 265 and 117 min, respectively. The patient's recovery was uneventful, and he was discharged from hospital 8 days after surgery.

An immunologically normal 52-year-old male developed fever and abdominal dilatation after coronary artery bypass grafting; this was followed by systemic erythroderma and granulocytopenia. In spite of all kinds of available treatments, the patient died of renal failure associated with digestive tract bleeding on the 47th postoperative day. The skin biopsy showed basel vacuolar degeneration and epidermal eosinophilic necrosis. Based on these clinicopathological findings, we made a diagnosis of graft-versus-host reaction (GVHR) after blood transfusion. After this experience, we are trying operation without transfusion or with using 1500rad irradiated blood. This anti-GVHR stratedy has yielded an increase in the rate of operation without transfusion and improvement of quality of the operation itself. Consenquently GVHR do not occur in consecutive 250 open cardiosurgeries.

Mycotic aortic aneurysm caused by Klebsiella pneumoniae (K. pneumoniae) is extremely rare and 3 cases of K. pneumoniae-induced mycotic aortic aneurysm are present, 2 of which were located in the aortic arch and the other in the suprarenal abdominal aorta. Urgent surgery was performed for 2 cases because of impending aneurysmal rupture and progressive septic shock, whereas elective surgery was performed after radical antibiotic chemotherapy for the other case. In-situ reconstruction with rifampicin-bonded prosthetic grafts was performed, and no infective complications have occurred in any of the cases.

We encountered a case of massive tricuspid regurgitation after corrective surgery for a ventricular septal defect. Fixation of the septal leaflet to the ventricular septum at the point where it was closed with a pericardial patch and marked annular dilatation were the lesions contributing to the severe tricuspid regurgitation. The posterior leaflet of the tricuspid valve was excised from the tricuspid annulus, slid to the adhering septal leaflet, and then reattached to a safe area of the septal leaflet to prevent conduction disturbance. The sliding repair was supported by annuloplasty with a Carpentier-Edwards ring, and a concomitant right-sided Maze procedure was conducted for atrial flutter.

Papillary fibroelastoma (PFE) commonly involves the native valve tissue, especially that of the left side of the heart. PFE originates less commonly from the valve of the right side of the heart and rarely from the valve chordae. A 69-year-old man was admitted to our hospital complaining of chest discomfort in October 2005. Transthoracic echocardiography showed a highly mobile round mass measuring approximately 10mm in diameter in the right ventricle. He underwent urgent surgery. The tumor was located at the middle of the tricuspid valve chordae and was excised under cardiopulmonary bypass with cardiac arrest. He had an uneventful recovery and was discharged from the hospital 15 days after surgery. The patient has been asymptomatic and remains well without tumor recurrence 7 months after surgery.

Heparin-induced thrombocytopenia (HIT) can often result in devastating thromboembolic outcomes. Argatroban is frequently administered as an alternative anticoagulant to heparin. We present a complicated case of HIT in which off-pump coronary artery bypass grafting was performed using anticoagulation with argatroban. Although the active clotting time was maintained between 220 and 270 s using argatroban, intraoperative thrombotic complications and postoperative prolonged coagulopathy were encountered. Learning objective: The use of argatroban involves a potential risk of inadequate anticoagulation or life-threatening postoperative bleeding depending on the dose. We recommend that the target ACT during off-pump coronary artery bypass grafting with argatroban should be strictly maintained over 250 s, although an ACT exceeding 300 s may cause prolonged coagulopathy>.

当院で経験した孤立性腸骨動脈瘤の3症例について報告する. 症例1は, 28歳男性で左腸骨動脈破裂により仮性動脈瘤を形成し, ショック状態で救急来院した. 緊急で左腸骨動脈人工血管置換術を施行した. 症例2は60歳男性で右下肢腫脹を主訴に来院. 動静脈瘻を合併した右総腸骨動脈瘤と診断し, Yグラフト置換および瘻孔部閉鎖術を施行した. 症例3は55歳男性で肝炎の経過観察中に腹部超音波検査で両側腸骨動脈瘤を指摘された. 両側の総腸骨動脈瘤の診断でYグラフト置換術を施行した. 孤立性腸骨動脈瘤は臨床症状に乏しく, 破裂, 動静脈瘻などの合併症ではじめて発見される場合も多い. 画像診断の進歩とともに今後は無症状での発見例も増加すると思われる.

Objective: Much more concern is recently paid to the cosmetics when simple congenital heart defect is repaired. Here we present the reversed U-shaped skin incision with lower partial sternotomy for juvenile or adult female patients. Methods: Four patients with atrial septal defect (ASD) and one patient with ventricular septa] defect underwent the operation with this method. Patients’ ages ranged from 5 to 46 years old. Results: Postoperative recovery in all cases was uneventful. Only the middle portion of the operative scar was visible when the breast was well developed. The scar was completely covered by the brassiere. A numbness of the upper medial portion of the left breast was recognized in one initial patient, who underwent ASD closure and concomitant right-side Maze procedure, necessitating a wider dissection than that used for other patients. Conclusion: A reversed U-shaped skin incision with a lower sternotomy could provide relatively comfortable operative fields for cardiac surgeons, and be cosmetically appealing to female patients who require a repair of simple congenital heart defect.

FIGURE 1. A and B, Endoventricular spiral plication technique schema. A, Ple in a clockwise direction. The remaining opening of the ventricle could be clos gathering the wall of the left ventricle (LV) and reducing the distance between longand short-axis magnetic resonance images (C and D, respectively) with t shape, and thickness of the left ventricular wall is revealed. RV, Right ventricle From the Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 28, 2011; revisions received Dec 16, 2011; accepted for publication Jan 4, 2012; available ahead of print Feb 1, 2012. Address for reprints: Arudo Hiraoka, MD, Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-1-10 Marunouchi, Okayama, 7000823, Japan (E-mail: bassbord1028@yahoo.co.jp). J Thorac Cardiovasc Surg 2012;144:269-70 0022-5223/$36.00 Copyright 2012 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2012.01.013

An 83-year-old female with aortic and mitral stenosis showed orthopnea. The aortic valve pressure gradient was 139 mm Hg. The mitral valve orifice was 0.92–1.05 cm2 and the right ventricular pressure was 70 mmHg. The body surface area of the patient was 1.23 m2. Double valve replacement was performed with 16mm CarboMedics pediatric bileaflet valve for the aortic position and 25 mm CarboMedics mitral valve for the mitral position. The patient leads a normal daily life with NYHA class II three years after surgery.

Anomalous origin of the right pulmonary artery is a rare congenital malformation and is usually fatal without early surgical correction. A 16-year-old patient, who had received no previous treatment, demonstrated abnormal findings on ECG. On cardiac catheterization, the pressure in the normally arising left pulmonary artery was found to be greater than the systemic level. Bidirectional shunting across a patent ductus was identified and aortography revealed that the right pulmonary artery arose from the posterior wall of the proximal ascending aorta. The presence of severe pulmonary vascular obstructive disease was anticipated and right lung biopsy was performed. The index of pulmonary vascular disease rating was 2.8 and the Heath-Edwards classification was grade 3. Consequently, we considered that corrective right pulmonary circulation could be maintained after correction, and total correction was performed. The postoperative course was uneventful and the pulmonary artery pressure reduced significantly. Discussion focuses on the surgical indications for such infrequent older cases and we conclude that preoperative lung biopsy is useful in identifying severe pulmonary vascular disease and evaluating indications for surgery.

Prosthetic graft infection in the ascending aorta or aortic arch is a life-threatening complication. Redo graft replacement is also associated with high mortality and morbidity rates. Conservative treatments without graft removal recently developed as alternatives to conventional surgical approach have been reported with successful outcomes. We report a case of successful treatment of prosthetic graft infection in the aortic arch, for which percutaneous catheter drainage was initially performed prior to open surgery, followed by graft coverage with an omental flap.