Pseudoaneurysm of the left coronary ostial anastomoses as a complication of the modified Bentall procedure diagnosed by echocardiography and multislice computed tomography

We report the case of a patient with a pseudoaneurysm of the left coronary ostial anastomoses diagnosed 6 years after a Bentall procedure with coronary button anastomoses had been performed. Preoperatively, the pseudoaneurysm of the ascending aorta was diagnosed by transesophageal echocardiography and multislice tomography, and the diagnosis was confirmed by surgery. Intraoperatively, the dehiscence of the button anastomosis of the left coronary artery was determined. The operative technique for the repair of the left coronary anastomosis dehiscence was direct closure through a sternotomy using extracorporeal circulation. The patient was discharged on the twelfth day without problems. In conclusion, we demonstrated that the patient with a pseudoaneurysm after a conduit operation of the ascending aorta can be prediagnosed by using echocardiography and multislice tomography.     

Mitral valve replacement for a severely calcified mitral annulus

We herein describe a surgical technique in a mitral valve replacement for a hemodialysis patient presenting with mitral valve stenosis and severe mitral annular calcification. Mitral annular calcification extending to the left ventricular myocardium was resected using a cavitron ultrasonic surgical aspirator (CUSA) to make a flat plane from the left atrium to the left ventricle. An autologous pericardium was secured to the posterior left ventricular wall and to the left atrial wall covering the mitral annulus for annular reconstruction. In the posterior mitral annulus, the prosthetic valve was fixed onto this pericardial patch. After the operation, the patient recovered well without any embolic complications. The prosthetic valve functions normally without any perivalvular leakage. Decalcification using the CUSA and the annular reconstruction with a pericardial patch is therefore indicated in valve replacement for patients with severe mitral annular calcification.     

Emergent left upper extremity revascularization following stent-grafting of the descending thoracic aorta in a patient with an aberrant left vertebral artery

Aim-Background

The indication for performing a left carotid-subclavian bypass in the case of an occluded left subclavian artery following endovascular stent placement in the descending thoracic aorta is not well established.

Case report

We describe a case report of a 72-year-old patient with a ruptured aortic isthmus and an aberrant left vertebral artery originating from the aortic arch, who was treated with emergent endovascular stent-graft placement in the descending thoracic aorta.In the immediate postoperative period, the patient complained of left upper extremity pain and loss of sensation, and the limb was pale. Arterial Doppler ultrasonography of the left extremity revealed monophasic arterial pulse waves associated with low flow velocities. The patient was taken to the operating room and was submitted to a left carotidsubclavian bypass using an 8mm PTFE graft.

Conclusion

In the present case immediate revascularization using a carotid-subclavian bypass is strongly indicated to relieve left upper extremity ischaemia due to the absence of collateral circulation from the vertebral artery     

Transesophageal echocardiography in the management of left atrio-femoral bypass during thoracoabdominal aortic aneurysm repair: a case report

PURPOSE: To describe the utility of transesophageal echocardiography (TEE) in a patient undergoing thoracoabdominal aneurysm (TAA) surgery using left atrio-femoral bypass (LAFB). CLINICAL FEATURES: A 57-yr-old female patient underwent repair of type II TAA. As per institutional routine, LAFB technique was used. Initial difficulty with the pump flow was encountered. TEE images showed that the left atrial cannula was positioned against the left atrial wall. The cannula position was adjusted and the pump flow was established. During different stages of the surgery, TEE was used to monitor the left ventricular cavity size and its function. This allowed the adjustment of LAFB pump flow relative to left ventricular filling and optimal fluid resuscitation in order to maintain both upper and lower body perfusion. CONCLUSION: In this patient, TEE was useful to confirm the correct position of the left atrial cannula and for hemodynamic management during LAFB.     

A novel application of cerebral oximetry in cardiac surgery

We report a novel use of cerebral oximetry in cardiac surgery using the Fore-Sight absolute cerebral oximeter (CAS Medical Systems Inc, Branford, CT). A patient with a persistent left superior vena cava underwent mitral and aortic valve replacement. We decided to tape and occlude the persistent left superior vena cava and used cerebral oximetry to compare left and right hemispheric oxygen saturation levels to ensure that cerebral perfusion was not impaired. The procedure was uneventful, and the patient was extubated 8 hours later without neurocognitive deficit.     

血栓闭塞性脉管炎合并动脉硬化闭塞导致下肢缺血的手术治疗

目的 探讨下肢血栓闭塞性脉管炎(thmmboangiitis obliterans,TAO)合并动脉硬化闭塞症(arteriosclerosis obliterans,ASO)手术治疗效果.方法 回顾性分析2007年治疗的TAO合并ASO 6例患者的资料.2例行腹主动脉切开取栓+内膜剥脱+腹主动脉-股深动脉人工血管旁路移植-胭动脉人工血管-小腿动脉自体大隐静脉旁路移植术,1例行腹主动脉切开取栓+内膜剥脱+腹主动脉-右股深动脉人工血管旁路移植-膝下胭动脉人工血管旁路移植术;1例行左髂总动脉-左股深动脉人工血管旁路移植一胫前动脉自体大隐静脉原位移植术,1例行左侧人工血管切开取栓+左股深动脉成形-膝下腘动脉人工血管旁路移植术,1例行右股总动脉-左股总动脉人工血管旁路移植-胫后动脉自体大隐静脉旁路移植术.结果 5例患者术后恢复顺利,1例于术后当天出现股动脉-腘动脉人工血管和远段的大隐静脉桥血栓形成,立即再次手术行人工血管和大隐静脉切开取栓术,并同时行胫后动静脉吻合.6例患者均痊愈出院,无死亡病例.5例患者的下肢远端静息痛完全缓解,1例部分缓解.足部溃疡的2例创面明显缩小,无感染发生.所有患者得到随访,平均随访为6.5个月,3例足部溃疡愈合.1例术后3个月出现左股部切口感染,最终行膝上截肢处理,残端一期愈合.其他5例患者的移植血管通畅,症状缓解.结论 对TAO合并ASO患者如果手术治疗方式恰当,可以取得比较好的疗效.     

Normal cardiac function with a hybrid heart.

A left ventricular bypass procedure using a cardiac allograft was performed in a patient with a long history of rheumatic heart disease and two aortic valve replacements. Normal cardiac function was reestablished, and the only problem following transplantation was that of serious arrhythmias involving the recipient heart. Eighteen months after left ventricular bypass bacterial endocarditis which was resistant to medical treatment developed on the aortic prosthesis. The patient underwent operation, the prosthesis was removed, and the recipient left ventricle was partially resected and excluded from the circulation. Since then the patient has been asymptomatic and, at the time of writing three years after cardiac allograft, he is our longest survivor.     

Thrombosis of the Left Brachiocephalic Vein After Subtotal Esophagectomy with Reconstruction Using a Retrosternally Shifted Gastric Tube: Report of a Case

We performed a right transthoracic subtotal esophagectomy with systemic three-field lymph node dissection, followed by reconstruction with a gastric tube shifted retrosternally into the left side of the neck, for esophageal cancer in a 62-year-old woman. The patient had an uneventful postoperative course until postoperative day (POD) 9, when a venous thrombosis originating from the left brachiocephalic vein and elongating to the left subclavian vein was detected occasionally on computed tomography scans, although there were no clinical symptoms. The left brachiocephalic vein seemed narrowed by compression from the reconstructed gastric tube, and this was considered the cause of the thrombosis. The patient was commenced on thrombolytic therapy, using urokinase, and on anticoagulation therapy, using heparin and warfarin. The thrombus had disappeared completely by POD 38. The anticoagulation therapy was continued for 6 months and no recurrence of the thrombosis has been detected in the 4 months since its completion.     

Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair.

OBJECTIVE: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches. METHODS: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7+/-8.2 years; mean time interval for development of aneurysm was 3.6+/-4.2 years; mean age at aneurysm surgery was 16.9+/-8.8 years. Residual left to right shunt was detected in 6 (46%) patients. RESULTS: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6+/-5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up. CONCLUSION: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-right-lateral positioning of the patient.     

A case report of epicardial cryoablation in a five-month-old infant with WPW syndrome

A five month old boy was referred to us with recurrent episodes of tachycardia and heart failure due to WPW syndrome. ECG and electrophysiological studies revealed a left lateral wall accessory conduction pathway. The patient did not respond to medical treatment and the division of the accessory pathway was performed by epicardial cryoablation methods through left lateral thoracotomy without using cardio-pulmonary bypass. Tachyarrhythmia and delta wave disappeared immediately following the operation and the patient had uneventful postoperative recovery. In this paper, the usefulness of epicardial cryoablation with left lateral thoracotomy for infants with a proved left accessory conduction pathway is stressed.     

Acute clinical deterioration in a patient with end-stage dilated cardiomyopathy and left ventricular thrombus formation

The case of a 17-year-old male patient with severe end-stage dilated cardiomyopathy and a large thrombus formation within the cavum of the left ventricle is reported. After an acute thrombectomia combined with a partial left ventriculectomy (Batista procedure), the patient was successfully treated with an appropriate left ventricular assist device (LVAD) system using a centrifugal nonocclusive pump (Biomedicus, Medtronic, Anaheim, CA, U.S.A.). Mechanical support was removed on Day 9, and the patient was discharged from the hospital on Day 19. The effectiveness of emergency mechanical support in patients with very unfavorable prognoses is discussed.     

The use of right ventricular support with a centrifugal pump in a case with right ventricular failure due to intraoperative right ventricular infarction

The patient was 67-year-old woman with mitral valve restenosis and regurgitation, tricuspid insufficiency, and left atrial dilatation who underwent mitral valve replacement, tricuspid valvuloplasty, and left atrial plication. The patient developed right ventricular (RV) failure due to RV infarction when she was weaned from cardiopulmonary bypass (CPB). Therefore, CPB was resumed to be followed by intra-aorta balloon pumping (IABP). However, complete response was not obtained. Thus, right ventricular support was performed using a centrifugal pump, and the patient could be weaned from CPB. Three days after surgery, the right ventricular support was discontinued, and IABP was removed 7 days after surgery without marked changes in hemodynamics. Although RV failure due to RV infarction is a serious intraoperative complication, favorable results were obtained by combination therapy with IABP and right ventricular support using a centrifugal pump in our patient.     

Repair of an anomalous left coronary artery

We describe a patient with an anomalous single coronary artery who presented with a syndrome of atypical chest pain. Coronary angiography revealed a single right coronary ostium, with a narrowed left coronary artery originating at the right coronary ostium. The proximal portion of the left coronary artery that was narrowed was noted to run in the aortic wall. We describe the operative management of this patient using ostial remodeling.     

Acute pulmonary embolism due to multiple hydatid cysts.

A case of acute pulmonary embolism due to multiple hydatid cysts is reported. Chest X-ray, echocardiography, spiral CT scan and MR-angiography were performed for the diagnostic evaluation. The patient underwent a left anterior thoracotomy and a left pulmonary arteriotomy in order to remove the hydatid cysts, without using extracorporeal circulation. The post-operative recovery was uneventful and the patient, 42 months later, has a normal life.     

Repair of a postinfarct ventricular septal defect on the beating heart. Surgical considerations

Postinfarct ventricular septal defect (VSD) still remains associated with a high mortality and morbidity. Despite the development of modern surgical techniques and medical care it continues to be a difficult therapeutic challenge. This report describes a case of a 70-year-old female patient, who presented with a postinfarct VSD after having anterior wall infarction. She presented with left heart failure, pulmonary hypertension and left to right shunt of 78% (Qp/Qs=4.3). The patient was operated on using cardiopulmonary bypass on the beating heart. The closure was performed with a Dacron-patch and a single bypass to the diagonal branch using the left internal thoracic artery. Postoperatively the patient did well and was discharged in good condition on the 13th postoperative day. We conclude that postinfarction VSD can be repaired on cardiopulmonary bypass avoiding cross-clamping. This method is helpful for the outcome as well as for the early postoperative recovery of elderly patients.     

A case of concomitant surgery of advanced valvular disease and lung cancer under cardiopulmonary bypass

We successfully performed a concomitant operation in a patient with severe valvular heart disease with a giant left atrium and a pulmonary cancer. The operation was done via a median sternotomy under cardiopulmonary bypass. The patient was a 62-year-old man with congestive heart failure, NYHA class III. The CT ratio was 76%, and the volume of the left atrium estimated by a CT scan was above 900 ml. An abnormal shadow was recognized in the left upper lung field. Mitral valve replacement with St. Jude Medical valve (31 mm), and tricuspid annuloplasty with a Bex Reducer were performed. After an autonomous cardiac rhythm and a decrease in the size of the left atrium were confirmed, we went on to remove the upper lobe of the left lung under cardiopulmonary bypass. Twelve months postoperatively, the patient was doing well. For a complex case such as the present one, we recommend lobectomy via a median sternotomy using cardiopulmonary bypass as the technique of choice. This method assures good hemodynamic control and provides improved visibility of the pulmonary hilus.     

Die Ruptur des Karotisbulbus – Eine seltene Komplikation nach Endarteriektomie

Rupture of the carotid artery wall is a very rare postoperative complication. Mainly ruptures of vein patches are described in the literature. This paper reports on a 51-year-old patient with elective endarterectomy of the left internal carotid artery using V-Y technique. On day 8 after operation, the carotid bulb ruptured. The suture line was not involved. The rupture was due to local wall necrosis, as verified by histologic examination. In an emergency procedure the necrotized tissue was resected and repaired using a Dacron patch. Postoperatively the patient showed paresis of the left recurrent nerve but fortunately did not suffer any other neurological deficit     

Successful repair of left ventricular pseudoaneurysm after mitral reoperation under hypothermic circulatory arrest

Successful repair of left ventricular (LV) pseudoaneurysm after mitral valve replacement (MVR) is uncommon, with delayed onset showing particularly high mortality. We report a case of delayed LV pseudoaneurysm onset after MVR reoperation. The patient had unique clinical symptoms, including coronary ischemia due to compression of the left main coronary artery by the aneurysm. Surgical repair was done using hypothermic circulatory arrest via left thoracotomy. The patient has experienced no cardiac events or pseudoaneurysm recurrence in the 7 years since surgery.     

Recurrent complicated colon diverticulitis in renal transplanted patient

Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.     

Clinical effects of ventricular assist system in end-stage cardiac failure. Advantages of left ventricular blood drainage for recovery from cardiac dysfunction.

OBJECTIVES: Heart transplantation is extremely limited currently in Japan. As a consequence ventricular assist system implantation is employed the patient falls into end-stage cardiogenic shock. This preliminary report describes our initial clinical experience with use of 2 kinds of ventricular assist system for 13 Japanese patients. METHODS: 7 patients were supported by a left ventricular assist system with blood drainage from the left atrium (LA drainage Group) using a Toyobo ventricular assist system, while another 6 patients were supported by a left ventricular assist system with blood drainage from the left ventricle (LV drainage Group) using the Toyobo ventricular assist system (1 patient) or TCI-LVAS (5 patients). RESULTS: The average duration of ventricular assist system support in the LV drainage Group was 112 days including two on-going patients (now at 39 days and 241 days) and in the LA drainage Group was 49 days. The average left ventricular ejection fraction at 3 weeks after ventricular assist system implantation was improved from 12.3 to 54% using the TCI-LVAS and from 14 to 33% using the Toyobo ventricular assist system with drainage from the left ventricle. However, this was decreased from 20 to 10% using the Toyobo ventricular assist system with drainage from the left atrium. The ventricular assist system was explanted in 4 patients (31%) with recovery of cardiac dysfunction and 3 were long survivors. The 2 on-going patients are awaiting heart transplantation. Thus the current survival rate overall is 38%. The survival rate (67%) is excellent in the LV drainage Group including 2 long survivors after explantation. CONCLUSION: Ventricular assist system support with drainage from the left ventricle seems to be more advantageous for cardiac functional recovery than from the left atrium for end-stage heart failure.