[Zasshi] [Journal]. Nihon Kyobu Geka Gakkai最新文献

A case of successful surgery for a rapidly growing aneurysm is described. The patient, a 47-year-old woman, had suffered from recurrent aphtous and genital ulcers for 17 years and hyperthyroidism for two years. One month after myocardial infarction, follow-up coronary angiography showed total obstruction at the distal part of the aneurysm in the left anterior descending artery with rapid dilation to 37 mm. Echocardiography revealed gradually increasing pericardial effusion. Urgent surgery was performed on January 11, 1995. Because Behçet's disease was suspected and since the vascular wall was suspected to have become fragile, surgery was performed using the aortic-no-touch technique. Under ventricular fibrillation, the proximal and distal part of the left anterior descending artery of the coronary aneurysm was ligated and bypass grafting was achieved at the distal part of the left anterior descending artery with the left internal thoracic artery. Low dose steroid treatment was started from nine days after surgery. The post operative course was satisfactory and coronary angiography during the first month showed no abnormal signs.

A 77-year-old woman was admitted to our hospital with congestive hepatic dysfunction and combined valvular disease. In addition to aortic stenosis, mitral stenosis, and tricuspid regurgitation, multi-organ dysfunction consisting of hepatic cirrhosis, pulmonary dysfunction and renal dysfunction were found. In consideration of the patient's anxiety for surgical treatment, we performed aortic valve replacement, open mitral commissurotomy and tricuspid annuloplasty. Although the patient required hemofiltration for 2 days and an assist of catecholamines for 1 month, she improved better and was discharged at 2 months after surgery. As preoperative assessment of preliminary function of other organs is difficult in the elderly, indications for surgery and optimal surgical procedures must be investigated in each case.

We reported a rare case of isolated tricuspid valve endocarditis in a non-addict with no underlying cardiac disease. A 48-year-old man was presented with high fever and newly developed leg edema. The diagnosis of tricuspid endocarditis was established following detection of a large vegetation (3.0 cm) on the tricuspid valve on echocardiography. One blood culture showed positive for Campylobacter fetus. At operation, a large and a small vegetation were found attached to the anterior leaflet of the tricuspid valve, and the septal leaflet was also found to be involved by the infective endocarditis. These leaflets were therefore removed and the tricuspid valve was replaced with CarboMedics valve. He has remained free of endocarditis for nineteen months after surgery.

The patient was a 67-year-old male. Preoperative DSA study revealed a right subclavian aneurysm, a brachiocephalic aneurysm, stenosis of the left common carotid artery and the left subclavian artery, and occlusion of the left vertebral artery. An intraoperative occlusion test of the right vertebral artery showed a decline of the brainstem auditory evoked responses (BAER) seven minutes after the start of the procedure. Cardiopulmonary bypass was established by femoral arterial and bicaval cannulation. Under selective cerebral perfusion by cannulation of both common caroid arteries, a partial aortic arch replacement was performed using a graft patch with 3 branches. These three branches were connected to the right subclavian artery and to both common carotid arteries, respectively. Under deep hypothermia the right vertebral artery was reconstructed with the saphenous vein graft. Proximal anastomosis between the saphenous vein graft and the right caroid graft was done perfusion from a branch of the saphenous vein graft in order to shorten ischemic time of basilar arterial region. The patient was weaned from bypass without problems. After weaning the BAER test was again performed and found to be normal. The postoperative course was uneventful. Postoperative DSA examination showed good blood flow in all the reconstructed vessels. This study suggests that deep hypothermia and shortening of ischemic time of the basilar arterial region are effective in preventing ischemic injury of the brain stem and the cerebellum.

A 49-year-old man was admitted to the hospital with swelling and redness overlying the left anterior chest wall. He had been treated by percutaneous transluminal coronary recanalization for acute myocardial infarction with central venous catheter one year and four months earlier. Since then, he had had no symptoms. An incision and drainage was performed and specimen showed acute and chronic granulation tissue containing pus with involvement of underlying left third rib and cartilage. Candida albicans was cultured from the drainage specimen. Treatment with fluconazole was began. The lesion failed to clear following incision and drainage, continuing to exude pus, then open surgical excision and curettage of the cartilage and rib was performed. After 2 months of therapy, the lesion had resolved. This is a rare case of candida costochondral osteomyelitis without a definite proof of former hematogenous candida infection.

A 81-year-old female was hospitalized with chest discomfort. Findings of CT scan revealed Stanford type A acute aortic dissection, but the dissecting lumen had already closed with thrombus. Aortogram showed no intimal tear, intimal flap or ulcer like projection. Under the diagnosis of "closing aortic dissection", conservative treatment was selected. The dissecting lumen was disappearing gradually, but she had a sudden chest pain on hospital day 4 and CT scan demonstrated an enlarged and enhanced dissecting lumen. She underwent an emergency operation and a hemiarch replacement was performed successfully. Her postoperative course was uneventful and she was discharged from the hospital in good health.

Blood cardioplegia has been widely accepted due to better oxygen delivery, pH buffering and free radical scavenge. We have found that a crystalloid cardioplegia solution formulated to accelerate anaerobic glycolysis with high buffering capacity. To conserve blood cardioplegia, we formulated a crystalloid cardiopletia containing 100 mM histidine for buffering. This cardioplegia (HBS) was compared to cold blood cardioplegia in patients requiring open heart surgery. Eighty patients including HBS (n = 28), and CBC (n = 40) were involved in this study. Left ventricular end-systolic elastance (Emax; mmHg/cm3) was evaluated pre- and postoperatively. Cardiac index and inotropic requirement were also monitored at 1, 3, and 12 hours after cardiopulmonary bypass. There was no death in either group. All hearts returned to previous rhythm in HBS group, whereas total 12 DC cardioversions were requested in 6 patients. Emax was significantly higher in HBS group (5.2 +/- 0.6 mmHg/cm3) than in CBC group (3.4 +/- 0.4 mmHg/cm3). Cardiac index was also significantly higher in HBS group postoperatively than in CBC group with lower inotropic requirements. We conclude that histidine containing crystalloid cardioplegia provides excellent recovery of cardiac performance with lower inotropic requirements in open heart surgery. The ease of use, and lack of blood are other important advantages of this crystalloid cardioplegia.

A surgical case of rare coronary artery fistula between the left circumflex artery and right ventricle was reported. A 46-year-old woman had suffered from exertional dyspnea and palpitation for three years. Pan systolic heart murmur was heard through the left 4th inter costal space. The chest X-ray film demonstrated cardiac enlargement and lung congestion, and the electrocardiograms showed atrial fibrillation and left ventricular hypertrophy when she was admitted to our hospital. Preoperative catheterization revealed a huge coronary artery fistula originating from the left circumflex artery and opening into the right ventricle through the posterior wall of the heart. The left-to-right shunt ratio was 60% and Qp/Qs was 2.47. At operation, the dilated circumflex artery fistula was carefully dissected and the tape was passed around the fistula as a tourniquet under extra corporeal circulation on the beating heart. To estimate myocardial ischemia, the fistula occlusion test was performed by tightening the previously placed tourniquet. Monitoring of electrocardiograms, transesophageal echocardiography, and hemodynamics were useful to detect myocardial ischemia. The occlusion test was performed under ECC for 5 minutes. No ischemic changes were observed. The fistula was interrupted under cardiac arrest at the point of the occlusion test.

From 1990 to 1996 we performed coronary artery bypass grafting using only arterial grafts. Both pre- and post-operative thallium-201 exercise myocardial scintigraphy were evaluated in 68 cases (161 grafts). The rate of improvement (%) was defined as follows: (number that showed improvement of perfusion of thallium on post-operative scintigraphy/number that showed decreased perfusion of thallium on pre-operative scintigraphy) x 100. Examination was made separately regarding cases of ischemia (102 grafts) and infarction (54 grafts). For ischemic cases, the rate of improvement using left internal thoracic artery (LITA), right internal thoracic artery (RITA) and right gastroepiploic artery (RGEA) was 80% (12/15), 70% (7/10) and 71% (5/7) respectively. For infarction cases, the rate of improvement using LITA, RITA and RGEA was 54% (7/13), 60% (6/10) and 53% (9/17) respectively. Among these three groups no significant differences were noted. As a result, RGEA is thought to have usefulness equivalent to LITA and RITA.

A sixty-two years old woman with a successful bypass grafting for coarctation of the thoracic aorta (Co-A) is presented. She has been suffering from hypertension since her thirties. Preoperative cardiac catheterization demonstrated Co-A with a pressure gradient of 100 mmHg. Angiography revealed the hypoplastic aortic arch with marked calcification and well developed collateral circulation. Right-sided intrathoracic bypass grafting using a 16 mm woven Dacron graft was placed between the ascending and descending aorta via a right sixth intercostal space. The patient had a good postoperative course with reduced pressure gradient of 10 mmHg. We recommend this procedure to be a safe and simple technique that can avoid injury to the collateral circulation to our knowledge, this is the most aged patient who underwent a successful surgical treatment for the Co-A in Japan.