Objective : Although dissection extending to the aortic root is a common finding, it is potentially fatal in patients with acute type A aortic dissection. The purpose of this study was to evaluate surgical results of acute type A aortic dissection with proximal involvement. The proximal extension of dissection, types of aortic root procedure and its feasibility were investigated. Methods : Between 1997 and 2011, 80 patients with acute type A aortic dissection underwent emergent operation. Results : Dissection reaching around the coronary artery orifice was observed in 28 patients. In 11 patients, both left and right coronary arteries were involved with aortic dissection. Aortic root replacement was performed in 4 patients. In 7 patients, the dissected aortic root was reinforced by GRF glue and proximal aorta was replaced with a graft. Among these patients, postoperative aortic root redissection with severe aortic regurgitation was observed in 5 patients during postoperative long-term periods. All of them required surgical re-intervention of the aortic root. In 17 patients, dissection was extended to the right coronary artery. Aortic root reconstruction was performed in 2 patients due to pre-existing annulo-aortic ectasia. The remaining 15 patients underwent proximal reinforcement with GRF glue. No patient showed dissection extending to the left coronary artery alone. Operative mortality was 11% and other types of complications concerning the aortic root was not observed. Conclusion : An acceptable outcome was demonstrated with our surgical strategy of proximal aortic dissection. For patients, in particular, with proximal involvement to both the left and right coronary arteries, redissection of the aortic root should be noticed as a late complication with considerable frequency. Special care should be taken for precise recognition of the proximal extension of dissection and appropriate surgical procedure including simultaneous aortic root replacement.

View full abstract

Among 62 patients who underwent hybrid arch TEVAR, which is a combination of supra-aortic bypass and TEVAR to treat arch aneurysm, 5 patients encountered postoperative cerebral infarction. In 2 patients, whose thoracic aorta were extremely shaggy, cerebral infarction were multiple and fatal. Other 3 patients, whose aorta were not shaggy, developed visual disturbance after TEVAR and minor cerebral infarction were detected in the area of vertebral artery. To prevent cerebral infarction after hybrid arch TEVAR, the blood flow from the left subclavian to vertebral artery is considered to be significant.

View full abstract

During the past 19.5 years, we performed open repairs of 666 non-ruptured abdominal aortic aneurysms (AAA) and iliac artery aneurysms regardless of the patient's age, previous abdominal surgery, or comorbidities. To evaluate our strategies, we reviewed octogenarians and patients with previous laparotomy, dividing them into several groups. (1) Octogenarians were divided into the EO-group (extremely-old patients, 85 years old or older : n=56) and the O-group (octogenarians, younger than 85 years old : n=113). (2) All cases operated by transabdominal approach (n=661) were divided into the A-group (with previous laparotomy : n=164) and the B-group (without laparotomy : n=497). (3) A-group was also divided into subgroups according to the kind of previous surgery : M-group (stomach or gall bladder surgery : n=120), C-group (colorectal surgery : n=20), Ao-group (aortic surgery : n=16), and S-group (colonic or urinary stoma constructing surgery : n=6). We introduced our clinical pathway in January 2000 and non-heparin technique in November 2000 for all AAA repairs. Non-heparin technique was revised in January 2003, excluding AAA with occlusive disease after several thrombotic complications. A comparison between EO-group and O-group proved that there was a significant difference only in aneurysmal diameter and frequency of renal impairment. Mean operation time (201±56 min vs 210±52 min), intraoperative blood loss (442±338 ml vs 430±242 ml), postoperative length of stay (9.4±5.0 days vs 8.2±2.8 days), and hospital mortality (0% vs 0.9%) were the same in both groups. Analyses of the consequences of previous laparotomy showed that A-group needed significantly longer exposure time (74±27 min vs 63±23 min : p=0.00001) and operation time (218±55 min vs 204±53 min : p=0.004) than B-group, but intraoperative blood loss (453±370 ml vs 449±274 ml) and transfusion rates (6.7% vs 8.5%) were the same in both groups. Because the data of M-group and C-group were similar to each other as well as those of Ao-group and S-group, we compared the perioperative data between M+C-group and Ao+S-group. Concerning exposure time, M+C-group required 6 min more than B-group and Ao+S-group 37 min more than M+C-group. The operation time of M+C group was 8 min longer than B-group and that of Ao+S-group was 45 min longer than M+C-group. Although there were significant differences in intraoperative blood loss (396±247 ml vs 820±701 ml : p=0.009) and transfusion rates (4.2% vs 22.7% : p=0.001) between M+C-group and Ao+S-group, postoperative length of stay (8.1±2.2 days vs 10.2±7.5 days) was almost the same, and the majority of patients (97.2% and 100% of respective groups) were discharged. Our experiences with clinical pathway and non-heparin technique suggest that open repair of AAA should not be refrained only for extremely old-aged patients or patients with previous laparotomies.

View full abstract

Studies have shown that postoperative disseminated intravascular coagulopathy (DIC) occurs in some patients with cardiac disease, acute aortic dissection, and ruptured abdominal aortic aneurysm. The specific pathophysiology of DIC in these settings are related to low cardiac function, shock, infection and sepsis as well as activation of coagulation cascade in the aneurysm sac or dissected aorta. A soluble form of recombinant human thrombomodulin (rhsTM) was approved in 2008 for the treatment of DIC. This report describes the safety and efficacy of rhsTM for the treatment of DIC in patients with cardiovascular disease operated in our department. Between October 2010 and March 2012, 35 patients with postoperative DIC were treated with rhsTM. Diagnosis of DIC was based on the diagnostic criteria for DIC of the Japanese Association for Acute Medicine (JAAM). During the first 6 months of the study period, after a diagnosis of DIC was made, the patients were treated with gabexate mesilate and antithrombin III, and if patients showed no improvement with conventional treatment, they received rhsTM for 6 days. During the last 10 months of the study period, patients received rhsTM soon after a diagnosis of DIC was made. Twenty seven patients survived for 28 days after rhsTM treatment, and the mortality rate was 22.9% (8/35). Patients who survived showed improvement in acute phase DIC scores, FDP levels, D-Dimer, fibrinogen and platelet counts during rhsTM treatment, but no improvement was observed in patients who died. No serious adverse events were found up to 28 days after the start of rhsTM administration. In conclusion, this study showed no adverse events of rhsTM, and further studies are needed to confirm that rhsTM administration is an effective therapeutic modality in the management of DIC after cardiovascular surgery.

View full abstract

The objective of this study was to assess the long-term outcomes of aortic valve replacement (AVR) for aortic valve stenosis (AS) in patients undertaking chronic renal hemodialysis at the time of the operation. Seventy five hemodialysis patients who underwent AVR between January 1993 and September 2012 were taken into account in this study. Operations included 40 isolated AVR and 35 concomitant AVR and coronary artery bypass grafting (CABG). Other combined AVR (mitral valve operation and aortic root operation) and emergency operations were excluded. Mean patients' age was 66.7 (±8.5) years and 53 out of 75 (70.6%) were male. The etiology of renal failure consisted of diabetic nephropathy (22 cases, 29.3%) and non-diabetic renal failure (53 cases, 70.7%). The mean duration of hemodialysis was 8.1 years. The operative mortality was 6.6%. The 1-year, 3-year, 5 year, and 10-year survival rates were 74.5, 42.1, 29.9, and 6.8%, respectively. Statistical analysis revealed that aortic valve area of less than 0.9 cm² and serum cholinesterase of less than 200 IU/l lead to significant risk for mortality (p<0.05). There was no clear difference between the outcomes of isolated AVR and concomitant AVR and CABG. This study suggests that earlier surgical intervention for AS in hemodialysis patients can improve the long-term outcomes, and serum cholinesterase can be a useful preoperative marker to assess operative results.

View full abstract

Para-anastomotic aneurysms may have dangerous complications such as rupture and thrombosis, with consequent loss of life. As these complications are associated with high mortality rates, early detection and prompt surgical treatment are important. Repair of para-anastomotic aneurysms may be challenging and the surgical approach should be carefully planned. A 66-year-old man had undergone thoracoabdominal aortic aneurysm repair 18 years previously. The diameter of the distal aortic anastomosis was gradually increasing. We comprehensively discussed the surgical approach preoperatively, including consideration of spinal cord protection. Abdominal aortic graft replacement was performed through a midline abdominal incision, with cross-clamping on the proximal side of the aneurysm, continuous intravenous infusion of naloxone, and segmental aortic clamping with distal aortic perfusion and selective visceral perfusion. The left renal artery was reconstructed, and the inferior mesenteric artery and lumbar arteries were preserved.

View full abstract

A 79-year-old woman with prosthetic valve endocarditis (PVE) on aortic position underwent re-aortic valve replacement. Although emergency operation was indicated due to huge vegetation over 20 mm in diameter attached to the prosthesis shown by preoperative transesophageal echocardiography, intraoperative transesophageal echocardiography showed disappearance of the vegetation. The prosthesis was carefully removed and replaced by a new bioprosthesis, though only small vegetation was observed on the removed prosthesis. Sudden blue toe 11 h after the operation and diminished pulse on right pedal artery suggested an acute arterial occlusion of a right lower extremity, requiring an emergency thrombectomy. Pathology diagnosed bacterial embolus with fresh thrombus that was considered apart from the prosthesis at the time of operation.

View full abstract

A 65-year-old man presented to our hospital with a chief complaint of hoarseness. Chest radiography and computed tomography detected a right subclavian artery aneurysm. The aneurysm had a maximum diameter of 85 mm, and was associated with a mural thrombus and displacement of the trachea to the left, which led to airway stenosis. In case ventilatory insufficiency developed during anesthesia induction, an extracorporeal membrane oxygenator was prepared, followed by administration of anesthesia. Careful administration of anesthesia allowed for anesthesia management without the extracorporeal membrane oxygenator. We approached the periphery and the proximal portion of the aneurysm through a right subclavicular incision and partial median sternotomy, respectively. After excision of the aneurysm, we performed EPTFE prosthesis implantation. The patient's postoperative course was uneventful, which led to postoperative improvement of the airway stenosis. The combination of a right subclavicular incision and partial median sternotomy is useful for the surgical treatment of large subclavian artery aneurysms such as the one in this case. Moreover, careful anesthesia management after close consultation with anesthesiologists is important for patients who exhibit preoperative airway stenosis.

View full abstract

A 62-year-old man underwent replacement of the ascending aorta for a Stanford type A acute aortic dissection. The proximal stump was reinforced with using internal and external PTFE felt strips, fibrin glue and cellulose fibers. However, hemolytic anemia and hematuria occurred postoperatively. ECG-gated reconstruction CT demonstrated that the hemolytic anemia was induced by collision of red blood cells on the inverted felt strip of the proximal anastomosis. The patient underwent a reparative procedure 1 week subsequent to the initial operation. During reoperation, half of the inner felt strip used for proximal stump fixation was found to be turned up and protruding into the inner lumen. An incision was made in the synthetic graft and the inverting felt material was removed as much as possible, and then a bovine pericardial patch was used as a means of covering the internal felt strip. Here, we report a rare case of hemolytic anemia at the site of an inverted inner PTFE felt strip used for reinforcement of proximal anastomosis. We found that an ECG-gated reconstruction CT is particularly useful in diagnosing this complication around a beating heart.

View full abstract

A 4-year-old boy was born with cyanosis and was given a diagnosis of tetralogy of Fallot and pulmonary atresia. Echocardiography showed membranous atresia of the pulmonary trunk that was connected to the left side of the ascending aorta via an aortopulmonary window 3 mm in diameter. Four major aortopulmonary collateral arteries (MAPCAs) were detected by cardiac catheterization and computed tomography angiography prior to undergoing surgery at 4 years of age. We performed one-stage complete unifocalization and definitive repair via a median sternotomy. The MAPCA supplying the left lower lobe was anastomosed to the true left pulmonary artery and the pulmonary artery trunk was augmented with an autologous pericardium patch. We then reconstructed the right ventricular outflow tract using a transannular patch and simultaneously patch-closed the VSD. The right/left ventricle pressure ratio after weaning from cardiopulmonary bypass was 0.8. The postoperative course was uneventful and the patient was discharged 26 days later. Seven months after the procedure, the right/left ventricle pressure ratio was decreased to 0.56 on cardiac catheterization.

View full abstract

A 52 year-old man was admitted to our institution with sudden onset of severe chest and back pain. The electrocardiogram showed ST segment depression in leads I, II, aVL, aVF, V3-6. Emergent coronary angiogram was performed, but the catheter did not reach to the coronary ostia, and it only performed false lumen aortogram. Computed tomography showed acute Stanford A aortic dissection. Ultrasound echocardiography also showed aortic regurgitation 3/4 degree. We decided to perform an emergency operation. During anesthesia induction, systemic blood pressure fell below 80 mmHg during systolic period, and pulmonary pressure raised to 60 mmHg. Transesophageal echography showed the movements of dissection flap intermittently obstructed the coronary blood flow and aortic valve annuls. Those flap movements, so called ‘flap suffocation’ was thought to be the cause of cardiac failure. Intra-operative findings of the ascending aorta showed an entry of dissection just above the left coronary ostia, and the entire detachment of intima to aortic wall. We performed ascending aorta replacement with aortic valve resuspension and fixation of coronary ostia. The postoperative course was uneventful, and he was discharged on the 25th postoperative day. For the precise treatment of acute Stanford A aortic dissection with such coronary ischemia, quick diagnosis and operative correction is essential.

View full abstract

Homozygous familial hypercholesterolemia is a rare metabolic disorder with characteristic clinical presentations, such as tendon xanthomas, hypercholesterolemia, and significant cardiovascular disease including premature coronary artery disease. We describe a case of a 56-year-old woman with homozygous familial hypercholesterolemia. She had been treated with low-density lipoprotein apheresis for 23 years. Preoperative echocardiography and coronary angiography showed severe aortic valve stenosis and right coronary artery stenosis. Aortic valve replacement with patch enlargement of the aortic valve annulus, and coronary artery bypass grafting were successfully performed. She was discharged uneventfully.

View full abstract

A 76-year-old woman, suffering from rapidly worsening dyspnea, and general fatigue was referred for evaluation and treatment of cardiac tumor. Echocardiography and computed tomography revealed a large tumor occupying the right atrium and inferior vena cava. We performed partial resection with cardiopulmonary bypass, in order to improve hemodynamics. The pathological examination suggested malignant lymphoma, diffuse large B-cell type. The patient was treated with cyclophosphamide, cyosine, arabinoside, etoposide, dexamethasone and rituximab (CHASER) postoperatively and gained complete response.

View full abstract

A 71-year-old man with double vessel disease (left anterior descending artery and right coronary artery) was surgically treated by off-pump coronary artery bypass grafting. He had undergone pre-sternal subcutaneous gastric tube reconstruction and mediastinal radiation therapy 19 years previously due to esophageal cancer. The gastric tube prevented the median sternotomy that is commonly necessary for cardiac surgery. In cases with difficulties of median sternotomy, left anterolateral thoracotomy and the use of the subclavian artery as inflow root for bypass grafting are available. Both radial arteries were harvested as graft conduit, because of prospective severe adhesion of left internal thoracic artery due to previous radiation. The radial artery was anastomosed on the back side of the left subclavian artery with side-to-end fashion. Y-shaped composite graft was made with the other arterial graft. Both ends were anastomosed to the left anterior descending artery and the right posterior descending branch on the beating heart status without cardiopulmonary bypass. Intra-operative SPY images showed good patency of both bypass grafts. The post-operative course was eventful. The catheter angiography revealed all graft patency 5 years after the surgery.

View full abstract

A pseudoaneurysm of the thoracic aorta after cardiac surgery is a rare complication, but can be life-threatening when it is ruptured. The pseudoaneurysm itself presents no symptoms in many cases, or may be similar to an atherosclerotic aortic aneurysm. Therefore, it is usually found incidently during imaging studies. We encountered 3 cases of pseudoaneurysm of the thoracic aorta that developed during the long-term follow-up after congenital cardiac surgery. None of the patients experienced specific symptoms associated with the pseudoaneurysm, and were diagnosed by chest roentgenograms and computed tomography. Most patients who undergo surgery for congenital heart defects as adolescents are free from medical treatment, and do not regularly see a doctor after the surgery. It is important to consider the possibility of a pseudoaneurysm in patients having a history of cardiac surgery.

View full abstract

A 62-year-old man had suffered from massive pedal edema, dyspnea and sinus bradycardia for 10 days. He had been heavy drinker for over 20 years. He was transferred to our hospital with severe heart failure. Echocardiography showed severe diffuse hypokinesis of left ventricular wall motion (EF20%) with dyssynchrony, and thrombus in the left ventricular apex. Under a diagnosis of LV thrombus due to severe heart failure, we made a plan for an emergency open heart surgery, but it could not be performed because of initial cardiogenic embolic stroke. Therefore, we waited for 2 weeks while performing anticoagulation therapy. The removal of LV thrombus and atrio-biventricular pacing for heart failure due to dyssynchrony were performed 2 weeks later. The pathological specimen of myocardium showed marked fibrous and hypertrophic change, which were similar to idiopathic dilated cardiomyopathy. Alcoholic cardiomyopathy due to alcohol intake for many years is similar to a clinical image of dilated cardiomyopathy, but its clinical prognosis by abstinence is not bad. In this case we performed an urgent open heart surgery due to cardiogenic embolic stroke, but must be essentially performed as an emergency operation. Postoperative course was uneventful and he was discharged 21 days after open heart surgery without any complications.

View full abstract

A 28-year-old man was involved in a traffic accident that sandwiched his chest between a wall and a truck. Shortness of breath and other symptoms started to appear several years later. Echocardiography at that time showed severe tricuspid regurgitation due to a failed valve and ruptured chordae in the anterior leaflet. He was followed up with medication. Leg edema developed at the age of 62 years and worsening symptoms of heart failure over a period of 6 months indicated a need for surgery. Intraoperative findings revealed the ruptured chordae attached to the anterior leaflet and a scarred myocardium at the septomarginal trabeculation. The tricuspid valve was surgically repaired, the anterior leaflet chordae were surgically reconstructed, an annuloplasty ring was implanted to address the tricuspid regurgitation and atrial fibrillation was treated using the Maze procedure. Surgery 34 years after trauma has improved hemodynamic cardiac function and normalized the cardiac rhythm in this patient.

View full abstract

Left atrial aneurysm (LAA) is extremely rare. We report a surgical case of LAA complicated with mitral regurgitation (MR) and severe heart failure. A 71-year-old man presented dyspnea and leg edema, followed by congestive heart failure. Transthoracic echocardiogram (TTE) showed moderate MR, deteriorated left ventricular function, and echo free space connecting to the posterior wall of the left atrium. Three-dimensional reconstruction of computed tomography (3D-CT) clearly showed the whole shape of the LAA and its location relating to surrounding structures. LAA was 5×6 cm, expanding to apex side, and originated from the posterior wall of left atrium between circumflex branch of the left coronary artery and coronary sinus. LAA wall extended to the mitral posterior annulus, causing annular deformity and MR. Mitral valve plasty and aneurysmorrhaphy were performed. Biventricular pacing leads were implanted for cardiac resynchronization therapy, because of severe heart failure. Postoperative 3D-CT showed reduction of the LAA with no deformity of coronary vessels. No MR was detected by postoperative TTE. The patient has recovered without any complication after our treatments.

View full abstract

We report a rare case of aortic root replacement after arterial switch operation (ASO). Ten years after undergoing ASO, a 10-year-old boy underwent a Bentall operation because of progressive aortic valve regurgitation and aortic root dilation. The operation was performed under the division of the right pulmonary artery. This view made it easy and safe to dissect the coronary arteries and to perform aortic root surgery.

View full abstract

We describe a case of cardiac surgery for a patient with CD36 deficiency. A 56-year old man had progressive dyspnea on effort for 1 year. On admission, echocardiography revealed severe aortic valve regurgitation. He required medical treatment for heart failure, and subsequently elective aortic valve replacement was planned. Pre-operative cardiac scintigraphy (¹²³I-BMIPP) showed total defect of myocardial uptake. CD 36 deficiency was diagnosed based on the characteristic findings. CD 36 deficiency could cause transfusion related complication by donor blood transfusion. We prepared 1,200 ml autologous blood preoperatively in a two week period. The operation was performed successfully without donor blood transfusion. He was discharged uneventfully.

View full abstract

A 54-year-old woman underwent abdominal aortic replacement for abdominal aortic aneurysm in March 2012. Approximately 6 months after surgery, she was taken by ambulance to hospital due to thoracodorsal pain, lower limb paralysis and pain. Emergency computed tomography indicated acute aortic dissection involving the ascending aorta, aortic arch, and descending aorta. The outline of the prosthesis implanted in the abdominal aorta was absent, and emergency surgery was performed immediately by median sternotomy to treat suspected complete obstruction. Following confirmation of brachiocephalic artery dissection, extracorporeal circulation was started with drainage of blood from the vena cava and the return via left axillary artery, plus perfusion in both lower limbs. However, the level of regional oxygen saturation declined as the flow of extracorporeal circulation increased. To solve this problem, an incision was made in the ascending aorta, and an aortic cannula was inserted directly into the true lumen. Aortic arch replacement was then performed, but this central repair failed to improve blood flow in both the left and right femoral artery. Proximal thrombectomy successfully removed a large amount of thrombi, but did not improve blood circulation. Left axillobifemoral bypass was subsequently performed, and improved lower limb blood circulation, but with residual motor impairment. Since the patient regained somatosensory sensation and was able to perform simple exercises, rehabilitation was started. Hemodialysis was required after abnormal increases in muscle enzyme levels and white blood cell count, but this was later discontinued following improvement of renal function. The patient was transferred to a rehabilitation clinic 54 days after surgery.

View full abstract