[Coronary endarterectomy and on-lay patch anastomosis in a case with unstable angina due to diffusely diseased coronary artery]

A 76-year-old woman with unstable angina due to diffusely diseased coronary artery successfully underwent coronary artery bypass grafting (CABG) using endarterectomy and on-lay patch anastomosis. She had triple vessel disease in the coronary artery and all of them were diffusely stenotic. It was impossible to undertake simple CABG. We were able to perform 3 coronary artery bypass grafting using endarterectomy and on-lay patch anastomosis. The postoperative course was uneventful and postoperative angiogram revealed well patent 3 grafts. Coronary endarterectomy and on-lay patch anastomosis were effective procedure in a patient with diffusely diseased coronary artery.

Acute pulmonary thromboembolism with a floating right-heart thrombus. 4 surgical cases

OBJECTIVE

We determined the efficacy of surgery for acute pulmonary thromboembolism with a floating right-heart thrombus.

METHODS AND RESULTS

Thrombi were diagnosed by transthoracic echocardiography and electron beam computed tomography in 4 patients with acute pulmonary thromboembolism with a floating right-heart thrombus, and thromboembolectomy was done in all patients. Surgical procedure included intermittent deep hypothermic circulatory arrest. One patient died of endobronchial hemorrhage and 3 survived.

CONCLUSION

Because acute pulmonary thromboembolism with a right-heart thrombus is life-threatening, immediate thromboembolectomy is required to decrease mortality.

[A case of left ventricular rupture and left ventricular-right atrial communication after mitral valve re-replacement]

We report a case of left ventricular rupture and left ventricular-right atrial communication after mitral valve re-replacement. A 53-year-old man was admitted to our hospital for a primary tissue failure of mitral xenograft. On June 4, 1997, he underwent mitral valve re-replacement. At 12 post operative day, he was suffered from unexpected dyspnea. The transesophageal echocardiography showed floated mitral valve and left ventricular-right atrial communication. The emergent operation was done. At the operation, posterior mitral annulus was disrupted and the disruption reached to a membranous septum. A communication was directly closed, mitral annulus was repaired with perigard and one size smaller mitral valve was implanted. The patient was discharged and returned to social life.

Aortocoronary saphenous vein graft aneurysm in redo coronary artery bypass grafting: report of a case

We report herein the case of an 80-year-old woman who underwent successful redo coronary artery bypass grafting (CABG) for a saphenous vein graft aneurysm found 10 years after her initial operation. On presentation, coronary angiography (CAG) revealed aneurysmal dilatation of the saphenous vein graft and severe stenosis of the left main trunk (LMT). A percutaneous transluminal coronary angioplasty (PTCA) of the LMT lesion was performed; however, a CAG after the PTCA revealed restenosis and the patient developed anginal chest pain at rest. Thus, repeat CABG was urgently carried out, which was followed by a good outcome. Histological examination of the aneurysmal dilatation showed a true aneurysm. Only 15 other cases of redo CABG for this indication have been reported, the features of which are also discussed.

[A case of isolated tricuspid valve endocarditis caused by Campylobacter fetus]

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.

[Surgical treatment for patient ductus arteriosus in an aged patient]

A successful closure of patent ductus arteriosus (PDA) in a 70-year-old women is described. The patient had poor pulmonary function and calcification of the aortic arch and the descending aorta, as well as arteriosclerosis obliterans bilaterally in the iliac arteries. We therefore performed trans-pulmonary artery direct closure of the ductus arteriosus via a median strenotomy. In surgery, we used a Foley balloon catheter inserted into the aorta through the ductus to prevent backflow. Leakage of blood from the ductus, even with use of balloon occlusion, required the reduction of perfusion flow to 500 ml/min and temporary circulatory arrest. Rectal temperature was 27 degrees C when the aorta was cross-clamped. The ductus orifice was primarily closed with three mattress sutures with pledgets, and this sutured orifice was secondarily covered with a bovine pericardial patch. The postoperative course was satisfactory. Trans-pulmonary artery direct closure of the PDA using cardiopulmonary bypass is useful for aged patients. This patient is, as far as our knowledge, the oldest surgical report in Japan.

[Hemodynamic effects of amrinone, phosphodiesterase inhibitor, early after coronary artery bypass grafting]

This study was conducted to evaluate the hemodynamic effects of amrinone early after open-heart surgery. Eighteen patients who underwent coronary artery bypass grafting were randomly divided into two groups: ten patients (group A) were administered 5 micrograms/kg/min of amrinone, and eight patients (group B) were administered 10 micrograms/kg/min. No bolus of amrinone was administered before continuous infusion. The mean and systolic arterial pressure and systemic vascular resistance index were significantly decreased (p < 0.05) after infusion of amrinone in both groups. Cardiac index was not increased in group A, but was significantly increased in group B without increase in the double product. There were no significant changes in heart rate, mean pulmonary arterial pressure or pulmonary capillary wedge pressure in either group. Pulmonary vascular resistance index tended to decrease in either group. Transient hypotension after infusion of amrinone was a serious clinical problem. Of the eight patients with systemic vascular resistance index less than 2000 dyne*sec*cm-5*m2 before infusion, blood pressure decreased below 100 mmHg in five patients. Administration of amrinone was discontinued in two patients in group B and one patient in group A because of transient hypotension. In this study, continuous infusion of amrinone (10 micrograms/kg/min) had both positive inotropic and vasodilating properties; however, transient hypotension must be monitored carefully.

[Successful surgical treatment for fungal endocarditis involving the aortic valve: report of a case]

A 50-year-old man who had undergone successful aortic valve replacement for fungal endocarditis was presented. He had been doing well until October 1993, when he suddenly developed shock with high fever. In two weeks he recovered from septic shock with vigorous medical treatment including intravenous administration of antibiotics. The infecting organism was not detected on repeated blood cultures. Four months later he was admitted to our hospital because of left heart failure. Although he was afebrile on admission, a two dimensional echocardiogram revealed vegetation on the aortic valve and massive aortic regurgitation. Inflammatory signs persisted and the vegetation increased in size, and therefore an aortic valve replacement was performed. A surgical specimen of the aortic valve revealed perforation in each of three cusps and vegetation on the non-coronary cusp. Pathological exploration revealed typical colonies of fungi. Following the diagnosis of fungal endocarditis, administration of an anti-fungal drug was started. His post-operative course was uneventful, and there was no evidence of recurrence with the anti-fungal medication for one year postoperatively.

[Mitral valve replacement and coronary artery bypass grafting for postinfarction mitral papillary muscle rupture]

A 79-year-old man was admitted to our hospital with heart failure following acute inferior myocardial infarction. An echocardiogram demonstrated severe mitral insufficiency, and coronary arteriography revealed double vesel disease. Following diagnosis of ischemic papillary muscle dysfunction, PTCA was performed, but the mitral insufficiency was not eliminated. Follow-up echocardiography disclosed rupture of the posterior papillary muscle. He underwent surgery on the 30th day after onset of acute myocardial infarction. Partial rupture of the posterior papillary muscle was found at surgery, and mitral valve replacement and single coronary artery bypass to Lcx were performed. His postoperative course was uneventful, and he was discharged on the 46th day after operation.

[Late pericardial effusion after open-heart surgery: usefulness of pericardiocentesis under echocardiographic guidance]

Late pericardial effusion (PE) after open heart surgery has a potential for serious complications, including tamponade necessitating urgent drainage. From October 1990 to March 1995 moderate to massive PE developed following 9 of 359 (2.5%) cardiac procedures between 11 and 55 days postoperatively (mean, 18.6 days). Only one of these nine patients had evidence of cardiac tamponade; the other 8 patients had moderate symptoms including malaise, weight gain, and dyspnea on exertion. All patients except one were being treated with warfarin and anti-platelet agents. Echocardiography detected posterior PE of variable magnitude in all 9 patients; anterior PE was present in only one of these patients. Pericardiocentesis under echocardiographic guidance using an echo transducer with a built in puncture needle was performed in all patients. A flexible catheter was left in place for 24 to 72 hours for suction. In each case, 300 to 712 ml of old bloody fluid (mean, 475 ml) was evacuated, with relief of symptoms. Despite continuing anticoagulant therapy, there was no recurrence of pericardial effusion. The technique we have described simplifies pericardiocentesis and helps to avoid complications in this procedure.

Echocardiography-guided pericardiocentesis with a needle attached to a probe

Pericardiocentesis with a needle attached to a probe was performed under two-dimensional echocardiographic guidance in 9 patients with pericardial effusion after cardiac operations. The first 5 mm of the tip of a puncture needle for percutaneous transhepatic cholangiodrainage is scratched with a scalpel to give the tip high echo intensity. When the probe is placed on the skin, the direction of puncture at that probe angle appears automatically on the monitor.

[Surgical repair of ventricular septal perforation following acute myocardial infarction in an 86-year-old man]

We reported on an 86-year-old man who underwent successful repair of ventricular septal perforation (VSP). He was admitted to our hospital with acute inferior myocardial infarction (MI). Color Doppler echocardiogram showed the VSP located in posterior ventricular septum and right heart catheterization revealed a Qp/Qs of 2.1. His hemodynamic condition worsened, necessitating initiation of intraaortic balloon pumping 11 days after the onset of MI. Surgical repair of the VSP was performed on that day. A posterior ventricular septal defect was repaired using the method advocated by Daggett: the ventricular septal defect was closed with a Teflon felt patch, and left ventricular free wall was closed with an artificial graft. The postoperative course was uneventful, and the patient is doing well at one year after operation. He was, to the best of our knowledge, the eldest patient to undergo successful operation for VSP in Japan.

[Early changes at anastomotic sites of saphenous vein grafts after coronary artery bypass grafting]

Saphenous vein grafts are known to develop intimal fibrocellular proliferation, however, there is little information regarding early changes of intimal fibrocellular proliferation after coronary artery bypass grafting (CABG). This study is based on 6 distal anastomotic sites obtained at autopsy from 3 patients who died within 9 days after CABG. The anastomotic sites were sectioned serially and studied with conventional and immunocytochemical techniques. Endothelial cells at all anastomotic sites showed desquamations. In two cases at 2 and 3 days after CABG, the luminal surfaces of anastomotic sites were covered by fibrin-platelet thrombus with infiltration of T-lymphocytes and macrophages. At these sites, moreover, some spindle-shaped cells were also present. Immunocytochemically, these spindle-shaped cells, which were stained with vimentin but negative with both anti-actin markers HHF35 and CGA7, were considered to be de-differentiated smooth muscle cells. In the case at 9 days after CABG, cellular reactions were mainly composed of macrophages and de-differentiated smooth muscle cells. In conclusion, these observations in human saphenous vein grafts at an early stage suggest that 1) endothelial denudation leads to adhesion of fibrin-platelet thrombus and subsequent cellular response. 2) T-lymphocytes and macrophages may play an important role in an early stage of intimal fibrocellular proliferation.

[A case of massive air embolism during cardiopulmonary bypass]

Massive air embolism during cardiopulmonary bypass is one of the most serious complications in open heart surgery. We report such an accident, which was managed by temporary retrograde perfusion through the superior vena cava. A 59-year-old woman with severe mitral stenosis underwent mitral valve replacement. Soon after the start of the bypass, a massive air embolism occurred, probably because a bend in the tubing caused the blood level in the oxygenator to fall. The pump was stopped immediately and the patient was placed in the deep Trendelenburg position. The pump circuit was primed rapidly with fluid and retrograde perfusion through the superior vena cava was done at a flow rate of 1.5 L/min for 5 min. After air return from the aortotomy was confirmed, the standard bypass procedure was resumed with hypothermia. When the accident was discovered, and until the end of the operation, deep anesthesia was induced with pentobarbital for protection of the brain. Mitral valve replacement and tricuspid annuoplasty were done in the usual way thereafter. Postoperatively, the patient had no neurologic sequelae except for transient generalized convulsions, and has returned to normal daily activities.

[Case of pseudocoarctation associated with aneurysm of the descending aorta]

A 55-year-old man was hospitalized for examination of a descending aortic aneurysm found on chest X-ray film. Aortogram and magnetic resonance imaging showed elongation and kinking of the arch and proximal descending aorta, which is associated with a descending aneurysm. A slit-like area of stenosis was found at the beginning of the aneurysm, but there was no pressure gradient across the stenotic lesion. The diagnosis of pseudocoarctation with aneurysm was done, and an operation was undertaken. The aneurysm and the kinking distal to the left subclavian artery were resected, and an artificial graft was inserted using partial cardiopulmonary bypass. This case is the tenth of pseudocoarctation associated with aneurysm reported in Japan.

[Coronary artery bypass grating 13 years after pneumonectomy]

Coronary artery bypass grafting (CABG) in a patient who had undergone left pneumonectomy for lung cancer 13 years earlier is described. Preoperative pulmonary function was reduced; percent vital capacity was 55% and percent forced expiratory volume in 1 second was 77%. Triple CABG was performed with saphenous vein grafts. A retractor designed for use in harvesting of the internal thoracic artery was useful to obtain a good operative view because the heart had shifted to the left. Oxygen tension of the arterial blood decreased transiently after extracorporeal circulation. The early postoperative course was uneventful and the patient was discharged on day 57 after the operation. This is the first report, to the best our knowledge, of CABG after pneumonectomy for lung cancer in Japan. We think it possible, with careful management, to perform open heart surgery on a patient after pneumonectomy if pulmonary function is adequate.

[A case of Günther vena caval filter insertion for recurrent pulmonary embolism]

We report that the Günther vena caval filter was successfully inserted in a case of recurrent pulmonary embolism resulting from ilio-femoral venous thrombosis. A 42-year-old woman was admitted to Osaka City University Medical School Hospital for dyspnea and chest pain on April 19, 1988. Pulmonary perfusion scintigraphy and pulmonary arterial angiography proved pulmonary emboli. The combination therapy of heparin and urokinase was performed, and her condition markedly improved. Then an ilio-femoral venography revealed only iliac vein compression but no thrombi. Therefore she was followed as an out patient with anticoagulant therapy. Nevertheless on April 10, 1989 she was admitted again complaining dyspnea and cyanosis. By venography at this time, some filling defects due to thrombi in right iliac vein were found. Therefore, we decided the insertion of the Günther vena caval filter for recurrent pulmonary embolism using Seldinger method via right internal jugular vein. We expect that the Günther vena caval filter will be useful for preventing pulmonary embolism resulting from ilio-femoral venous thrombosis because its procedure is easy, non-invasive and without significant complications.