Fuyuhiko Yasuda

Changes in False Lumen After Transluminal Stent-Graft Placement in Aortic Dissections Six Years’ Experience

Background—Transluminal stent-graft placements (TSGPs) are a new, less invasive procedure now recognized as the choice for aortic disease repair. Treatment of aortic dissections with TSGPs has resulted in good early results, but the long-term results and changes in the false lumen have not been elucidated in detail. Methods and Results—TSGPs were performed in 49 patients with primary tears in their descending aortas, and the follow-up period ranged from 4 months to 6 years. The patients were divided into 32 acute-onset and 17 chronic dissections; of the acute-onset cases, there were 15 Stanford type A retrograde dissections. Periodic enhanced spiral CT was conducted after TSGP. The false lumen in the ascending aorta in 14 (93%) of the Stanford type A cases was obliterated completely within 3 months. The CT study was continued for >2 years for 17 acute-onset dissection and 11 chronic dissection patients. The average false lumen diameters of the proximal, middle, and distal descending aorta before treatment were 15.9, 16.2, and 15.6 mm in the acute-onset dissection group and 28.1, 25.2, and 21.0 mm in the chronic dissection group, respectively. The false lumen diameters 2 years after treatment were 3.0, 3.7, and 3.1 mm in the acute-onset dissection group and 10.6, 10.5, and 11.9 mm in the chronic dissection group, respectively. Two years after TSGPs, the false lumen of the thoracic aorta totally disappeared in 76% of the acute-onset dissection group and 36% of the chronic dissection group. No cases showed rupture after TSGP. Conclusions—Complete obliteration of the false lumen is more likely in acute-onset cases than in chronic cases.

Long-Term Follow-up After Carpentier-Edwards Ring Annuloplasty for Tricuspid Regurgitation

BACKGROUND Use of flexible rings for tricuspid ring annuloplasty is becoming popular. This study was undertaken to evaluate Carpentier-Edwards (C-E) rigid ring annuloplasty for tricuspid regurgitation (TR), secondary to mitral valve disease and clinical outcome on a long-term basis. METHODS From December 1985 to March 1996, 45 patients with secondary TR underwent C-E ring annuloplasty. Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. The mean follow-up was 96.7+/-48.5 months or 362.6 patient-years. RESULTS There were three in-hospital and nine late deaths that were not related to tricuspid annuloplasty. Actuarial survival at 10 years was 68.3%. Echocardiographic studies showed that TR was well controlled within grade 2+ in all survivors. Residual pulmonary hypertension (PH) was recognized in 9 of 21 patients (42.9%) with preoperative PH, however, no TR was seen in 6 patients. A TR grade of 2+ was observed in 3 patients. Thirty of the total survivors (96.8%) were in NYHA class I and II, but 1 patient was in NYHA class III. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5%. CONCLUSIONS C-E ring annuloplasty is acceptable for repair of secondary TR and improvement in clinical status on a long-term basis.

Aortoesophageal fistula—relief of massive hematemesis with an endovascular stent-graft

A 59-year-old man with an esophageal carcinoma developed massive hematemesis due to aortoesophageal fistula after irradiation therapy reached 58 Gy. Emergent treatment with an endovascular stent-graft was successfully performed and the patient followed an uneventful course until he died of pneumonia 4.5 months later, which was caused by a tracheoesophageal fistula. Stent-graft repair is a safe and effective method to treat aortoesophageal fistula and may be an alternative to surgical resection.

Limitations of endovascular treatment with stent-grafts for active mycotic thoracic aortic aneurysm

An 81-year-old woman with ruptured mycotic thoracic aortic aneurysm was treated with endovascular placement of stent-grafts fabricated from expanded polytetrafluoroethylene and Z-stents. Although exclusion of the aneurysm was achieved at the end of the procedure, a type I endoleak developed on the following day. Despite emergent surgical resection of the aneurysm and extra-anatomical reconstruction, the patient died 2 days later. Stent-graft repair may not be a suitable method for the treatment of ruptured mycotic aneurysm in the presence of active infection.

Pulmonary leiomyosarcoma extending into left atrium or pulmonary trunk: complete resection with cardiopulmonary bypass☆☆☆★★★

Primary pulmonary leiomyosarcoma is a rare tumor. Few cases have been treated surgically because of its rapid invasion into the pulmonary trunk or heart and tendency toward massive intrapulmonary metastases. We report the cases of two patients with leiomyosarcoma originating in a pulmonary artery or vein that involved the pulmonary trunk or left atrium, both of whom underwent complete surgical resection with cardiopulmonary bypass (CPB). Since their operations, these patients have shown no evidence of recurrent tumor. PATIENT 1. A 72-year-old woman with persistent cough, chest pain, and hemoptysis was referred to our hospital for evaluation and treatment of presumed pulmonary thromboembolism. An angiogram revealed filling defects in the pulmonary trunk, absence of filling of the left main pulmonary artery, and decreased arterial filling in the left lung. A biopsy specimen was obtained from a tumor in the left main pulmonary artery by means of a suction catheter, and the pathologic diagnosis of sarcoma was made. Computed tomography disclosed a mass occluding the left main pulmonary artery and densely filling pulmonary artery branches. Median sternotomy was performed and CPB was applied. The left pulmonary veins were ligated and the left main pulmonary artery was incised. A large tumor completely filled the left main pulmonary artery. Extension of the incision into the pulmonary trunk disclosed that the tumor invaded its wall laterally on the left. The portion of tumor located in the left main pulmonary artery and pulmonary trunk, including the left main pulmonary artery and the left lateral wall of the trunk, was excised. Direct suture closure of the pulmonary trunk was carried out and CPB was terminated. The left main bronchus was transected and left pneumonectomy was completed. Fig. 1 shows the resected left lung and pulmonary artery. Tumor in the main pulmonary artery extended intraluminally into its branches. The tumor was diagnosed histologically with the aid of immunohistochemical stainFrom the Department of Thoracic and Cardiovascular Surgery, Mie University, School of Medicine, Tsu, Japan.

Successful repair of an aortoesophageal fistula with aneurysm from esophageal diverticulum

Aortoesophageal fistula is a rare, frequently fatal, cause of upper gastrointestinal bleeding, and there are few reported survivors of it. We report a successful surgical case of aortoesophageal fistula associated with an infective thoracic aortic aneurysm. The patient had been diagnosed as having an esophageal diverticulum 8 months before admission. The aortoesophageal fistula was completely resected, followed by esophagojejunum anastomosis and patch closure for the entry of the aneurysm and omental coverage to the wall of the descending aorta in one stage. In this case, esophageal diverticulum was diagnosed before the development of an aortoesophageal fistula associated with an aneurysm.

Surgical repair of extracardiac unruptured acquired valsalva aneurysms

Two cases of extracardiac unruptured Valsalva aneurysms due to rare causes are reported. One patient had been suffering from hyper eosinophilic syndrome. Operative corrections consisted of total replacement of the aortic root. The other patient had an aneurysm of just noncoronary sinus of Valsalva and a dilated ascending aorta due to cystic mucoid degeneration. Replacement of the ascending aorta with patch closure for the aneurysm was successfully performed.

Our experiences for off-pump coronary artery bypass grafting to the circumflex system

BACKGROUND Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience. METHODS From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube. RESULTS Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate. CONCLUSIONS With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.

Midterm Results of Mitral Valve Repair with a Rigid Ring

当施設において過去5年間にrigid ringを使用した僧帽弁形成術63例を対象に術後僧帽弁閉鎖不全症(MR)およびleft ventricular diastolic dimension (LVDd)を追跡し,rigid ring使用の是非を検証した.術式は腱索再建20例,quadrangular resection42例,ring annuloplastyのみ15例であり,これら全例にCarpentier-Edwards ringを使用した.これらの症例において手術成績,手術前後のMR,LVDdを追跡し,平均追跡期間41.2ヵ月までの再手術率,弁関連合併症回避率,生存率につき検討を行った.また人工弁輪サイズによる遠隔期でのMR制御能およびring縫着後の弁口面積についても検討した.結果として,入院死亡はなく,心エコー上,退院時II度以上のMR残存例は認めなかった.MRは術前平均3.13度から術後0.28度へと減少し,LVDdは術前平均58.4±6.71mmから術後平均48.7±6.3mmへと減少した.術後平均追跡期間41.2ヵ月での再手術例は2例(32%),mortalityは3/63,4.8%であり,死亡例はいずれも他疾患によるものであった.術前と術後遠隔期のMR(0～4度)を人工弁輪サイズ30mm以上のL群と28mm以下のS群で比較すると,L群で術前3.17度,術後遠隔期0.42度,S群で術前3.13度,術後遠隔期0.25度であり,S群において遠隔期のMR制御能は良好であった.Rigid ring縫着後の弁口面積を心エコーで調べた結果,CE26で平均2.85±0.62cm2,CE28で2.95±0.38cm2,CE30で3.09±0.49cm2であり,臨床上MSが問題となった症例は認めなかった.MRに対する残存MRを制御することを目的にrigid ringを使用した弁形成術の成績は良好であった.

Recent Surgical Results of Transverse Aortic Arch Replacement.

当科で行っている弓部大動脈瘤手術の脳保護法,末梢吻合における工夫について報告する.対象は1997年2月から2001年10月までに施行した弓部大動脈瘤手術32例.疾患の内訳は真性瘤18例,解離性大動脈瘤13例,仮性瘤1例で,緊急症例を9例含む.脳保護法は順行性脳灌流(SCP)と逆行性脳灌流(RCP)を組み合わせて用いている.つまり循環停止後,瘤を切開すると同時にRCPを開始,病変を検索し1分枝以下の再建ならRCPのまま手術を進め,2分枝以上の再建が必要ならRCP下に血液を逆流させながら弓部分枝にカニュレーションしSCPに移行する.また末梢側吻合の工夫として,急性解離ではadventitial inversion法,真性瘤では自己心膜を大動脈内面に補填することで止血の補助とした.最近の10症例ではカフ付きグラフト法を用いており,これにより手技的に非常に容易となり,すばやく確実な吻合が可能である.以上の方針の結果,術後覚醒時間8.7±1.4時間,病院死2例(6.3%),脳合併症2例(6.3%)であった.弓部大動脈手術の手術成績向上には安定した脳保護法の確立と,迅速で確実な末梢吻合を行うことにある.今回報告した脳保護法,末梢吻合における当科の方法は手術成績からみて有用である.