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

Composite valve graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. However, a major drawback in this operation is bleeding from the proximal suture line and coronary anastomosis especially in patient with friable root tissue involved by aortic dissection. We describe here a modified technique to take advantage of the aortic button and cabrol techniques to reattach the coronary artery ostia. We have experienced seven patients with the aortic root replacements for type A dissection using the described technique over the past two years. In view of our favorable experience, we recommend this technique especially for patient with acute dissection involving nondilated aortic annulus, in addition to the patients with Marfan syndrome or annulo-aortic ectasia.

The indications for a video-assisted lobectomy are currently ill-defined. Clinicians recommend based on the extent of lymph node involvement. Fifty-nine patients with clinical stage I non-small cell lung cancer underwent lobectomies with systemic lymph node dissections through a standard thoracotomy (Group C), and 26 patients underwent lobectomies with lymph node dissections using the video-assisted procedure (Group V). The number of dissected lymph nodes at all node levels were compared between the two groups. There was no significant difference between groups in the total number of dissected lymph nodes in patients with right lung cancer. The number of dissected hilar and interlobar lymph nodes, however, was less in Group V than that in Group C (hilar: 1.2 +/- 0.4 vs. 2.8 +/- 0.6, interlobar: 1.1 +/- 0.4 vs. 2.1 +/- 0.4). The total number of dissected lymph nodes in patients with left lung cancer was significantly less in Group V than that in Group C (18.5 +/- 0.3 vs. 28.7 +/- 2.4). In addition, the number of dissected lymph nodes in pratracheal, pretracheal, tracheobronchial, subcarinal, hilar, and interlobar lymph nodes were significantly less in the group V than those in Group C. Although there was no significant difference in the actual survival rates between the groups in this preliminary study, a sufficiently small number of dissected lymph nodes in the video-assisted lobectomy may have resulted in inaccurate staging and poor prognosis in these patients.

Early postoperative results were studied in 50 cases of coronary artery bypass graft (CABG) using a radial artery (RA). The patients ranged in age from 37 to 81 years, with the mean age of 61 years. Of them, 49 were male. An average of RA was 17.6 cm at completion of detachment and 15.6 cm when the graft was cut for use. The internal diameter before anastomosis an average of 3.7 mm on the proximal side and an average of 2.8 mm on the distal side. RA was anastomosed with ascending aorta in 47 cases, with the left internal thoracic artery in 2 cases and with the right internal thoracic artery in one case on the proximal side. RA was anastomosed with the left anterior descending branch area in 6 cases, with the left circumflex branch area in 40 cases and with the right coronary artery area in 4 cases on the distal side. There was no case of operative death, but one patient died while in hospital. The cumulative patency rate of the RA grafts was 95% (n = 40). Early postoperative results of the RA graft were satisfactory, therefore the RA graft were satisfactory, therefore the RA graft was an excellent alternative conduit for myocardial revascularization.

The prognosis in patients manifesting shock following acute myocardial infarction due to total occlusion of the left main trunk (LMT) is usually very poor and so is the lifesaving rate. Accurate judgement and rapid response are key to the successful management of this disease. We experienced a successful case with emergency coronary artery bypass grafting (CABG) on the 14 the day after initial attack. The patient, who had total occlusion of LMT, underwent a PTCA (percutaneous transluminal coronary angioplasty) during the initial attack under cardiac massage. We think in situations where patients have cardiac arrest, shock, elevated CPK levels suggesting devastation of myocardium due either to LMT or severe triple vessels disease, early catheter intervention rather than emergency CABG would be much more tolerable as long as hemodynamic situation allows. Our previous experience taught us that immediate surgical intervention with CABG usually resulted in poor outcome. Further refinements regarding the surgical procedure, technique, assist circulatory supports, cardioplegia, etc., are indispensable before trying to have a successful emergency CABG.

A case of pseudoaneurysm of the aortic arch which protruded to the retrobronchial space is reported. A 73-year-old female complaining of severe chest pain was transferred to our hospital, CT showed an abnormal mass which occupied the retrobronchial space and displaced the esophagus toward righ, associated with left pleural effusion. A pseudoaneurysm of the aortic arch was suspected. Angiography revealed an aortic arch aneurysm protruding to the retrobronchial space. Emergent total arch replacement was performed. We diagnosed it as an impending rupture of the aortic arch aneurysm with a specific shape.

We experienced a rare case of the mitral regurgitation due to papillary muscle rupture after percutaneous transvenous mitral commissurotomy (PTMC). This case was a seventy years old female who underwent PTMC. The cardiac tamponade and mitral regurgitation occurred after PTMC. Pericardial drainage was done immediately, and the next day the emergency operation was required. Rupture of the posterior papillary muscle was found at the operation, and mitral valve replacement was performed. Her postoperative course was uneventful and she discharged on the 26th day after the operation. We should take the papillary muscle rupture into consideration if there are severe sub-valvular lesion and shorting of the chorda.

We analyzed cases with brain damage after surgery for thoracic aortic aneurysm in our institution and investigated the causes, risk-factors and preventive measures for this disastrous postoperative complication. Irreversible brain damage was a complication in 25 out of 184 operative cases (13.6%) over a 21-year period. The cause of brain damage was determined to be embolism by manipulation of the aorta in six cases, clamping of the left subclavian artery in four cases, technical problems of separate cerebral perfusion (SCP) in four cases, severe shock in three cases, embolism unrelated to operative maneuver in three cases, stenosis of a branch of the arch with aortic dissection in two cases, and air embolism, circulatory arrest with insufficient hypothermia and hypoperfusion of a temporary bypass to the left carotid artery in one case each. The neurological symptom improved in eight cases and was unchanged in 17 cases. Eighteen cases died in the hospital. In the univariate analysis, age (p = 0.048), a portion of the aneurysm (p = 0.035), preoperative brain complication (p = 0.003), emergency operation (p = 0.033) and clamping of the arch (p = 0.001) were found to be prominent risk factors for brain damage. In the multivariate analysis, clamping of the arch (p = 0.0310), SCP (p = 0.0327) and emergency operation (p = 0.0223) were prominent. To prevent postoperative brain damage, the arch should not be clamped, appropriate operative techniques to avoid bleeding and to shorten SCP time should be employed, and proper and prompt management of the emergency operation and caution in clamping the left subclavian artery are considered to be necessary.

We report a case of surgical correction of a 65-year-old female. She presented severe congestive heart failure and preoperative cardiac catheterization showed massive left to right shunt (87%), mild mitral regurgitation, severe tricuspid regurgitation and pulmonary hypertension. The operative procedure consisted of annuloplasty of mitral valve (Kay's method), patch closure of the ostium primum defect and annuloplasty of tricuspid valve. Postoperative examination showed complete competence of mitral valve and improved functional capacity. This is the fourth successful case report of surgical correction of incomplete endocardial cushion defect in patients older than 65-year-old in Japan to our knowledge. Surgical correction of incomplete endocardial cushion defect should be recommended even in elder patients.

A 57-year-old woman in whom an abnormality was detected on the chest X-ray presented with no signs or symptoms other than hypertension. Several examinations revealed that she had aortic coarctation of the isthmus with two aneurysm in the arch. One aneurysm was located in the root of the left subclavian artery, another was just distal of the first aneurysm. For prevention of rupture of the aneurysms and treatment of hypertension, aortic arch reconstruction was performed with the aid of selective cerebral perfusion. The postoperative course was uneventful and she was discharged 19 days after the operation with normalization of her blood pressure. At the operation in this case, the combination of the two approaches, median sternotomy and left 4th thoracotomy, was useful.

The optimal approach for reoperation following repair of aortic coarctation (CoA) or interruption (IAA) remains controversial. Four patients underwent extra-anatomic bypass for restenosis after repair of CoA or IAA. The age ranged from 4 to 12 years. The initial repairs for two CoA, one type A-IAA, and one type B-IAA consisted of two grafting, one subclavian arterial turning-down aortoplasty, and one subclavian flap aortoplasty. All of them underwent during infancy. Preoperative right arm systolic pressure ranged from 140 to 190 mmHg ar rest. Through a midline sternotomy and an upper laparotmy incision, an extra-anatomic bypass from the ascending aorta to the supraceliac abdominal aorta was employed using a 12 to 18 mm tube graft. All patients survived surgeries, and their hypertension markedly improved. Our experience confirms safety and effectiveness of this option in selected young patients with re-stenosis of following repair of CoA or IAA.