Off-pump coronary artery bypass (OPCAB) has recently increased in popularity, but the longterm results are still unknown. We evaluated the mid-term results of OPCAB surgery using multi-slice computed tomography (MSCT), which is a non-invasive postoperative evaluation method. Thirty-one consecutive patients who underwent OPCAB surgery at least 2 years prior to the study were selected. The age was 50 to 79 years (66.9±6.5) and the ratio of men to women was 26: 5. Coronary angiography was performed in all patients at 2 weeks postoperatively. The follow-up was complete, and mean follow-up was 30.9 months. There were no hospital deaths and 1 non-cardiac late death. The graft patency rate in coronary angiography was left internal thoracic artery (LITA) 30/30 (100%), right internal thoracic artery (RITA) 2/2 (100%), radial artery (RA) 14/15 (93%), saphenous vein graft (SVG) 15/17 (88%). No graft became occluded on MSCT study and all patients have been angina-free during the follow-up period. We suggest that OPCAB is feasible in most patients with good patency and low mortality. MSCT is an effective follow up method for the morphological findings and noninvasive quantitative evaluation of the bypass grafts.

View full abstract

Between 1987 and 2002, 22 internal iliac artery aneurysms in 14 patients were repaired. In 13 we performed aneurysm excision or reconstruction. There were 3 cases in which simple proximal ligation of the internal iliac artery was performed; in 2 of these CT scans confirmed that the reduction of the internal iliac artery aneurysms was not recognized, but blood flow was not shown in the aneurysm. However, 6 years postoperatively 1 patient was confirmed with an expansion of the aneurysm, and blood flow was seen on a CT scan. In the 2 latest patients, the blood pressure of the internal iliac artery was measured before and after proximal clamping of the internal iliac artery, but the blood pressure of aneurysms could not be fully lowered by proximal ligation of the internal iliac artery. Therefore, endoaneurysmorrhaphy seemed to be the operative method of choice for treatment of the internal iliac artery aneurysms.

View full abstract

We encountered 4 nonagenarian cases of ruptured abdominal aortic aneurysm (RAAA). They were 2 men and 2 women aged between 90 and 94. Two cases were saved but two were lost. The percentage of success in this age group was low but there was no statistical inferiority. The serum hemoglobin levels on admission were low and they had a tendency towards acidosis in spite of fairly good blood pressure. The causes of death were hemorrhagic shock and intestinal necrosis. We have to treat more carefully and vigorously to secure elderly surgical cases of RAAA. One patient died of cerebral infarction after discharge. We recommend that the patients of RAAA in nonagenarians should undergo surgical operations except in cases of severe shock or cardiopulmonary arrest.

View full abstract

Between January 1999 and August 2002, 13 patients with mitral regurgitation resulting from native valve endocarditis underwent surgery. The age of these patients was 54±13.8 years (range, 27 to 74 years); 8 patients were men. Five patients were categorized as New York Heart Association functional class III or IV. Endocarditis was active in 3 patients. Emergency or urgent surgery was required in 4 patients. Twelve patients underwent repair, and one had a valve replacement. Following the removal of all infected or nonviable tissue, a decision was made as to the possibility of repair. Repair was attemped in 13 patients and was successful in 12 patients. Most patients received ring annuloplasty with a Carpentier-Edward ring. Six patients had chordae ruptures, 5 patients had vegetations, and 2 patients had elongated chordae. Twelve patients were categorized as New York Heart Association functional class I, and one was categorized as class II at discharge. There were no hospital deaths. The mean follow-up of the 13 survivors was 24±14 months (range from 3 to 43 months). There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidities. We conclude that mitral valve repair is an effective treatment for inective endocarditis with mitral regurgitation.

View full abstract

To determine the effects of a selective cerebral perfusion (SCP) technique under deep hypothermic circulatory arrest (DHCA) for aortic arch surgery, the neuropsychological outcomes of 38 patients with cardiovascular disease were examined before and after the operation. Thirteen patients undergoing aortic arch repair with SCP under DHCA (SCP group) were evaluated with 2 batteries of neuropsychological tests (Benton Visual Retention Test and Miyake's Verbal Memory Test) resulting in 4 subscores, and the results were compared with those of 15 heart surgery patients who underwent a normal cardiopulmonary bypass (CPB group) and 10 patients who underwent abdominal aortic aneurysm repair without CPB (Y group). There were no significant differences in age, incidence of preoperative cerebrovascular complications, or mean score on the preoperative neuropsychological tests among the groups. In the postoperative period, the patients in all 3 groups performed less well than they did preoperatively on 3 of 4 subscores, however, there were no differences among the 3 groups. On 1 of 3 subscores, the postoperative mean score in the SCP group was significantly lower than the preoperative and postoperative mean scores in the Y group, whereas there were no differences between the SCP and CPB groups. In the SCP group, the patients whose postoperative mean score was lower than the preoperative score had longer SCP times than the patients without a lower postoperative mean score. In conclusion, CPB, including SCP, may be a risk factor for the deterioration of postoperative neuropsychological function, although each group had deteriorated test scores in the early postoperative phase and the severity of the deterioration was not exceedingly high using our SCP methods. Various factors, such as drugs, anesthesia, surgical technique, and physical and psychological damage are believed to potentially have an effect on deteriorated postoperative neuropsychological function.

View full abstract

A 3-year-old girl was given a diagnosis of coronary arteriovenous fistula associated with a single right coronary artery on cardiac catheterization. The left coronary artery arose from the proximal part of the right coronary artery. The dilated left coronary artery ran in front of the right ventricular outflow tract and then divided into the left anterior descending branch and the left circumflex artery. A coronary arteriovenous fistula was in the left main coronary artery and opened into the right ventricular outflow tract. Under cardiopulmonary bypass and cardiac arrest, a transverse incision was made at the right ventricular outflow tract 1cm below the dilated vessel and the 5-mm oval-shaped orifice of the fistula was identified. This fistula was closed with a pledgetted mattress suture reinforced with over-and-over suture. Catheterization 8 months after surgery demonstrated no residual shunt and she has been doing well.

View full abstract

The patient was an 86-year-old man, whose medical history included pulmonary tuberculosis, pulmonary emphysema, hypothyroidism, subtotal gastrectomy for gastric cancer and proctectomy for rectal cancer. Since he suffered sick sinus syndrome (bradycardia-tachycardia syndrome), a DDD pacemaker was implanted using the right subclavian vein approach. Three months later, he suffered from a pacemaker infection of Methicillin-resistant Staphylococcus aureus. We performed extraction of the infected pacemaker system and implanted a new pacemaker. Because he had thoracic deformity, colostomy, and was in poor condition in general, we implanted the myocardial electrode through a small thoracotomy at the 6th costal bed under local anesthesia. The postoperative course was uneventful and there was no relapse of infection. Although this method is conventionally performed under general anesthesia, it is also possible to perform it under local anesthesia in selected patients. This method could be an alternative when endocardial electrode insertion is very difficult.

View full abstract

Horseshoe kidney is an unusual abnormality occurring in 0.25% of the population. In surgery for AAA with horseshoe kidney, reconstruction of aberrant renal and preservation of renal isthmus is important. We report 3 cases of AAA with horseshoe kidney treated successfully without division of the isthmus.

View full abstract

A 74-year-old woman had undergone right axillo-bifemoral bypass for infrarenal aortic stenosis due to aortitis syndrome in another hospital. She was admitted as an emergency case to our hospital with a ruptured thoracoabdominal aortic aneurysm, and an emergency operation was performed. We used arterial cannulation to the artificial vascular graft implanted for axillo-bifemoral bypass and first cooled the body temperature to below 25°C, then dissected the aorta. In the case of ruptured descending and thoracoabdominal aortic aneurysm, profound hypothermia is a valuable adjunct for unexpected blowout rupture during the preparation of the aneurysm and spinal cord and visceral protection.

View full abstract

Emergency operation was performed for 2 cases of acute pulmonary embolism which showed floating thrombi in the right atrium and right ventricle. Case 1 was a 48-year-old man without any contributory past history. Case 2 was a 65-year-old woman with a history of old myocardial infarction and chronic left heart failure with only 19% of the left ventricular ejection fraction. Although their preoperative hemodynamics and respiratory conditions were stable, ultrasound examination revealed floating thrombi in the right heart. Sudden death could have occurred if the occlusions had migrated to the pulmonary artery. Thus, emergency operation was selected instead of thrombolysis. During operation, the blood pressure suddenly decreased before the establishment of the cardiopulmonary bypass in both cases. This may have been the result of sudden additional pulmonary embolism, because no floating thrombi were noted in the right atrium or right ventricle at operation. After operation, case 1 recovered quickly although case 2 was discharged only after 6 months. It is highly possible that the presence of right heart thrombi change the hemodynamics rapidly. Therefore, emergency operation is necessary even when the hemodynamics and respiratory condition are stable. Thrombectomy is recommended even to patients such as case 2 in a serious condition, because this surgical procedure under cardiopulmonary bypass has been proven to be very safe.

View full abstract

The extremely rare occurrence of a case of spontaneous rupture of the aortic arch is reported. The patient was a 55-year-old woman who underwent a medical examination at a hospital following a sudden onset of chest pain. After a diagnosis of having cardiac tamponade was established, she was transferred to our hospital. She was in a state of shock with systolic blood pressure recorded at 70mmHg. Computerized tomographic findings indicated cardiac tamponade and hematoma around the ascending aortic arch but no aortic dissection. She was diagnosed as having a ruptured aortic arch and an emergency operation was performed. Apertures were observed on the anterior arch and were closed by a suture under halted circulation. Transesophageal echography was used to correctly identify the aperture on the rupture during the operation. Pathologic findings also indicated only extramural hematoma on the ascending aortic arch without the dissection. The patient's postoperative progress was satisfactory, and she was discharged after spending 16 days in the hospital. Spontaneous rupture of the thoracic aorta is extremely rare; it cannot be accurately diagnosed and leads to poor prognosis. Even in a case without trauma and aortic aneurysm, this disease should be diagnosed through rapid and detailed examination using computed tomography, and aggressive surgical treatment should be performed.

View full abstract

A 75-year-old woman required aortic valve replacement for aortic stenosis. She had undergone radical mastectomy and irradiation for left breast cancer 25 years previously, and had chest wall infection secondary to osteoradionecrosis. In spite of preoperative infection controls including surgical debridement, the chest wall was not healed well and colonized with MRSA. However, she was too ill with severe heart failure to wait until the chest wound was negative for MRSA for a valve operation. With the infection remaining, the aortic valve was approached through a right parasternal incision, to exclude the infected sternum from the surgical site, and successfully replaced with a mechanical valve. An internal mammary retractor was useful to avoid fractures of the infected sternum and provided excellent exposure of the aortic root. No mediastinitis or prosthetic valve infection was encountered postoperatively.

View full abstract

A 60-year-old woman was admitted because of dyspnea and a cough. Computed tomography and transthoracic echocardiography showed a tumor in the left atrium. However, transesophageal echocardiography alone could show the tumor and its extension in the interior wall of the left atrium. Peripheral blood chemistry showed a high CA125 level. The first operation was carried out in order to perform a complete resection of the tumor which was 3.5×4.0×2.0cm, but the interior wall of the left atrium seemed normal. The CA125 level returned to within a normal range 80 days after the first operation. Histopathology showed the tumor had myxomatous changes and ring structure formations, but malignancy was also suspected. Transthoracic echocardiography performed 14 months after the first surgery showed a recurrence of the tumor, and subsequent transesophageal echocardiography showed the tumor and its invasion in the interior wall of the left atrium. A second operation was performed to resect the tumor, which had invaded a part of the left atrial interior wall. The histopathology showed the tumor was myxoid but had mitoses and foci of necroses. This tumor was consistent with a myxosarcoma. The patient died as a result of a recurrent tumor blocking the left atrium 20 months after the first surgery.

View full abstract

A 39-year-old woman with Marfan's syndrome was referred with a symptom of exertional dyspnea, had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and Stanford B type chronic aortic dissection. She was successfully treated with a one-stage operation, consisting of aortic root replacement with the Carrel patch method, mitral valve replacement and extended replacement of the thoracic aorta (ascending, arch and thoracic descending aorta), through median sternotomy and left antero-axillary thoracotomy. This operation was performed under hypothermic circulatory arrest with continuous retrograde cerebral perfusion. The postoperative course was uneventful. Although the operation may include complicated procedures, it is important to perform a sufficient operation corresponding to the patient's condition and lesions, employing the most advanced surgical techniques, such as circulatory arrest, myocardial protection and so on.

View full abstract

A 64-year-old woman who had a fever and low back pain was referred to our institution. Abdominal computed tomography revealed a low density area around the aorta and inferior mesenteric artery and liver abscess. Under the diagnosis of mycotic abdominal aneurysm, intravenous administration of antibiotics was started and her symptoms improved. On the 12th day after admission, the patient developed hematemesis and an emergency CT scan revealed enlargement of the low density area around the aorta and dilatation of the inferior mesenteric artery diameter to 16mm. Urgent operation was performed under the diagnosis of impending rupture of the mycotic aneurysm. Necrotic tissue and hematoma was recognized outside the aorta, and this mass firmly adhered to the duodenum. Communication between the abdominal aorta and the duodenum through the inferior mesenteric artery was confirmed. The infected aneurysmal area of the aorta was almost completely resected by closing the infra-renal aorta and terminal aorta above the bifurcation and a left axillo-femoral bypass was established. The culture of the necrotic tissue revealed Klebsiella pneumoniae. Antimicrobial therapy was continued and the patient was discharged from the hospital on postoperative day 46. Because the mortality rate of mycotic aneurysm penetrating to the duodenum is high, early diagnosis and treatment is important. We present a successfully treated case of mycotic aneurysm in which the formative course was observed from an early stage of infection. We observed the process of mycotic aneurysm formation and aorto-duodenal fistula generation despite antibiotic therapy. Close observation of periaortic inflammation and early surgical intervention is necessary in such patients.

View full abstract

A 6-year-old boy was admitted with infective endocarditis and aortic regurgitation. Clinical signs of infection were severe. The leukocyte count was 13, 100/μl and the C-reactive protein (CRP) was elevated to 17.2mg/dl. Blood culture was positive for Staphylococcus aureus. Echocardiography showed a vegetation 3mm in diameter on the aortic valve, and a perforation of the right coronary cusp with moderate aortic regurgitation. With antibiotic therapy, clinical signs and laboratory data of infection improved at an early stage. We decided to operate after his complete recovery from infection. Laboratory data normalized completely in 6 weeks, but echocardiography demonstrated aneurysmal change of the right coronary sinus and severe aortic regurgitation. The Ross operation was performed on the 44th day. At operation, it was noted that the non-coronary cusp was destroyed completely leaving only strings of fibrous tissue. A perforation of 3mm in diameter was also found on the right coronary cusp. There was a mural aneurysm near the right coronary orifice without abscess formation in the surrounding structure. A pulmonary autograft was transplanted to the aortic root after resection of the destroyed aortic cusps, aortic root and the mural aneurysm. The right ventricular outflow tract was reconstructed using an autologous pericardium as a posterior wall and the Monocusp ventricular outflow patch (MVOP) #22 as an anterior transannular patch. The postoperative course was uneventful. Postoperative echocardiography revealed no aortic regurgitation.

View full abstract

A 54-year-old man was admitted to our hospital because of hypertrophic obstructive cardiomyopathy (HOCM). Medical treatment was not effective. Cardiac catheterization showed a peak systolic pressure gradient of 143mmHg between the left ventricle and the ascending aorta. Echocardiogram showed a systolic anterior motion and moderate mitral regurgitation without asymmetric septal hypertrophy. He underwent mitral valve replacement (MVR) with a 27-mm SJM instead of myectomy due to his relatively thin ventricular septum of 16mm. Postoperative cardiac catheterization revealed no significant pressure gradient between the left ventricle and the ascending aorta. MVR is the most effective surgical treatment of HOCM without asymmetric septal hypertrophy.

View full abstract

A 63-year-old woman was admitted to our hospital for combined valvular disease with tricuspid valve stenosis. Aortic and mitral valves were replaced with artificial valves and tricuspid valve were replaced with a biological valve. We chose artificial valves for the aortic and mitral valves because the patient was younger than 70, while a biological valve was used for the tricuspid valve to avoid possible thromboembolism. The postoperative course was excellent. We propose that it is better to use a biological valve for the tricuspid valve, even if artificial valves are used in other sites.

View full abstract

A 71-year-old man was transferred to our hospital because of impending rupture of an abdominal aortic aneurysm (AAA). Preoperative CT scan demonstrated a huge aneurysm of the aortic arch (TAA) associated with an AAA. Emergency coronary angiography revealed 3-vessel disease. One-stage surgery including TAA repair, coronary bypass surgery, and AAA repair was performed to avoid the possibility of rupture of the remaining aneurysms and the risk of ischemic heart diseases. One-stage surgery is a possible approach for patients with severe multivascular diseases.

View full abstract

An isolated quadricuspid aortic valve is an extremely rare congenital anomaly and there have been few surgical case reports published. A 47-year-old man with untreated diabetes mellitus was admitted to our institution because of fever and dyspnea. Transesophageal echocardiography showed severe aortic valve regurgitation and a quadricuspid valve with vegetations. Blood culture revealed Streptococcus agalactiae. Despite administration of antibiotics and treatment of his heart failure, the infection and heart failure were not controlled. Therefore, we performed aortic valve replacement in the presence of active infective endocarditis. The aortic valve had 2 equal-sized larger cusps and 2 equal-sized smaller cusps. There were vegetations on each cusp and an annular abscess was detected. The resection site of the abscess was reinforced with an autologous pericardial patch, and the aortic valve was replaced using a 21-mm SJM valve. His postoperative course was uneventful and he was discharged after recovery.

View full abstract