Koji Tsuchiya

Acute pulmonary embolism after cerebral infarction associated with a mobile thrombus in the ascending aorta

Although the causes of stroke are diverse, thromboembolism due to a mobile aortic thrombus is rare. We describe a surgical case of acute massive pulmonary embolism after critical cerebral infarction associated with a mobile ascending aortic thrombus in a 52-year-old woman. Concomitant surgical removal of the aortic thrombus and pulmonary embolectomy was performed successfully, and the patient has been stable without recurrent thromboembolic complications after 18 months of follow-up.

Surgical Repair of Left-Sided Cervical Aortic Arch Aneurysm: Case Report and Literature Review

Cervical aortic arch (CAA) is a rare vascular malformation which sometimes accompanies other cardiovascular malformations. Surgical approaches such as a lateral thoracotomy and a median sternotomy are selected depending on the position and type of aneurysm and other associated malformations. We herein report the case of a CAA patient who was a 38-year-old female and demonstrated an aneurysm between the left common carotid artery and left subclavian artery in addition to the persistence of the left superior vena cava (PLSVC). During surgery, the aortic arch from the distal right brachiocephalic trunk bifurcation to the proximal left subclavian artery bifurcation was replaced with a prosthetic graft to reconstruct the left common carotid artery. The median sternotomy approach was selected. Hypothermic circulatory arrest was performed using a cardiopulmonary bypass (CPB), and anterograde cerebral perfusion was conducted from the brachiocephalic trunk. The patient was discharged from the hospital without any complications 16 days after surgery. Magnetic resonance angiography was useful for diagnosing the precise position of the aneurysm. When encountering an aneurysm associated with the CAA in the transverse aortic arch or PLSVC, the median sternotomy approach is considered the treatment of choice.

Mitral valve repair for extended commissural prolapse involving complex prolapse.

We reviewed our experience of mitral valve repair techniques for extended commissural prolapse involving complex prolapse of either or both leaflets, due to chordal rupture or elongation. Between June 1991 and January 2005, 21 of 210 patients who underwent mitral valve repair for mitral regurgitation had extended commissural prolapse involving either or both of the anterior and posterior leaflets. There were 17 (81%) patients with degenerative and 4 (19%) with infective endocarditis. The distribution of diseased mitral commissural lesions was: posteromedial commissure in 14 (67%) patients, anterolateral in 6 (29%), and bilateral in 1 (5%). Reconstructive techniques included leaflet folding plasty in 10, resection-suture in 6, the sliding technique in 2, commissuroplasty in 2, and chordal shortening in 1. There were no perioperative deaths; postoperative mitral regurgitation was none or trivial in 19 patients and mild in 2. The mean follow-up period was 54 months (range, 2–155 months), and no patient required re-operation. There was one late death from a noncardiac cause at 103 months. Mitral valve repair for extended commissural prolapse is satisfactory. We consider leaflet folding plasty and its modification to be effective in patients who require extensive leaflet resection in the commissural area.

Aortic operation after previous coronary artery bypass grafting : Management of patent grafts for myocardial protection

OBJECTIVES Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. METHODS From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. RESULTS The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. CONCLUSION Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.

Saccular descending thoracic aortic aneurysm with dysphagia.

A 76 year old woman had suffered from chest pain, back pain, and dysphagia for 8 months. She was diagnosed as having a thoracic aortic aneurysm by chest X-ray and chest enhanced computed tomography. Simultaneously, severe dysphagia developed. Chest enhanced computed tomography and chest aortic aortography at our hospital demonstrated a saccular descending thoracic aortic aneurysm. Esophagography demonstrated that the esophagus was compressed by the aneurysm; therefore, a graft replacement for the saccular descending thoracic aortic aneurysm was performed on February 17th, 1998. A left sided 6th intercostal approach was made, and graft replacement for the aneurysm using a 22 mm Hemashield prosthetic graft was performed under temporary bypass from the thoracic aorta just distal to the left subclavian artery and to the left femoral artery. The postoperative course was uneventful, the severe dysphagia improved dramatically, but a pleural effusion of 1000 ml collected 3 weeks after the operation. Surgical cases of saccular descending thoracic aortic aneurysm with dysphagia are rare, and with this in mind, we report this case to the the medical literature.

Penetrating Knife Injury to the Heart

A 39-year-old man attempted to kill himself using a small knife to penetrate the left anterior chest wall because of trouble at work and with his girlfriend. On arrival at the emergency room, his consciousness was not clear and vital signs were unstable. The knife remained vertically located in the left anterior chest wall. A large left hemothorax was identified by chest X-ray, and moderate cardiac tamponade was detected by echocardiography. Left-sided chest drainage was performed by inserting a chest drainage tube, and about 2500 ml of hemorrhagic effusion was drained. An emergency operation was performed to relieve the cardiac tamponade and repair the penetrating cardiac injury. About an hour after arrival at the emergency room, a median sternotomy was performed in the operating room. The knife had injured the surface of the right ventricular outflow tract, the left lung, and the 3rd intercostal artery and vein. Cardiopulmonary bypass was immediately prepared for the repair of the cardiac injury. The wounds were successfully repaired with pledgeted sutures under cardiac beating. The postoperative course was uneventful with no sign of infection. The patient was discharged at 9 days after the operation. Here we have reported a case of successful surgical repair of a penetrating knife injury to the heart, which was managed by immediate resuscitation and emergency surgery.

A refined flanged Bentall technique using Valsalva tube graft for proximal reinforcement

Bleeding from the proximal suture line during aortic root replacement using a composite valve graft is a crucial and catastrophic problem. We present a simple flanged Bentall technique using a Valsalva tube graft to eliminate bleeding from the proximal suture line. The method is to wrap the proximal anastomosis completely by sewing the Valsalva flange to the residual aortic wall. The wrapping is facilitated by the use of part of a horizontally stretching Valsalva graft. This refined technique is effective and reproducible to prevent bleeding from the proximal suture line after the Bentall procedure.

Surgical repair of postinfarction ventricular septal rupture

OBJECTIVES Postinfarction ventricular septal rupture is fatal without surgical repair because of heart failure and secondary multiple organ failure. We investigated surgical results of postinfarction ventricular septal rupture and discussed the surgical strategy of postinfarction ventricular septal rupture. METHODS Twelve patients (mean age 71.3 +/- 7.4 years, with range from 61 to 81 years) underwent surgical repair of postinfarction ventricular septal rupture, from 1990 to 1998 in our Institute. There were 6 women and 6 men. The ventricular septal rupture was anterior in 10 patients and inferior in 2. The operative technique for anterior ventricular septal rupture was reconstruction of the septum with a Dacron patch after infarctectomy, according to the method of Daggett et al. For posterior ventricular septal rupture, reconstruction of the septum with a Dacron patch after infarctectomy was performed and the ventricular incision was closed with a two-layer patch. Coronary artery bypass grafting was performed in 5 patients for severe proximal coronary artery stenosis using saphenous vein grafts. RESULTS Overall hospital mortality was 0%. A postoperative residual shunt was recognized in 3 patients, but all were well-controlled conservatively and re-operation was not needed. The patients have been followed up for a mean of 59.5 months. There have been two late deaths due to non-cardiac problems. Acturial survival rate for the 12 patients was 90% at 1 year and 75% at 5 years. CONCLUSIONS The Daggett method is simple and fast, and is an effective and reliable technique for the repair of ventricular septal rupture.

Modified Elephant Trunk Technique in Distal Anastomosis With the Aid of Antegrade Selective Cerebral Perfusion for Total Arch Replacement

BACKGROUND Secure distal anastomosis and reliable brain protection are indispensable for successful total arch replacement (TAR). In 2002, we introduced a modified elephant trunk technique, a novel approach to distal anastomosis, and employed antegrade selective cerebral perfusion. We retrospectively analyzed 107 consecutive patients to evaluate the efficacy of this technique for TAR with antegrade selective cerebral perfusion. METHODS Since 2002 we have employed moderate hypothermic circulatory arrest, selective antegrade cerebral perfusion, and open distal anastomosis with a modified elephant trunk technique in TAR. Between February 2002 and September 2011, 107 TARs were performed in 88 males and 19 females (age, 33 to 88 years; mean, 70.9±9.5 years). Etiologies of cases were as follows: 89 true aneurysm due to atherosclerosis; 5 infectious aneurysm; 1 aortic dilation with bicuspid aortic valve; 12 aortic dissection, including 1 of acute aortic dissection case; and 2 Marfan syndrome. Concomitant procedures included 19 coronary artery bypass grafting (CABG) cases, 2 aortic valve replacement cases, 1 mitral valve plasty case, 1 Bentall procedure case, and 1 case of Bentall with CABG. RESULTS The operative mortality within 30 days was 0.9% (1 of 107), and overall hospital mortality was 1.9% (2 of 107). Temporary and permanent neurologic dysfunction occurred in 5 patients each (4.7%). The Kaplan-Meier survival analysis revealed a 5-year survival rate of 91.8%. CONCLUSIONS The modified elephant trunk technique using selective antegrade cerebral perfusion provided secure distal anastomosis and demonstrated excellent results, with low operative mortality and few neurologic complications.

Forty-year durability of a Smeloff-Cutter ball valve prosthesis in the mitral position

A rare case requiring replacement of an intact Smeloff-Cutter ball prosthesis in the mitral position 40 years after implantation is presented. The Smeloff-Cutter ball valve prosthesis was designed to have two open cages. It has two potential advantages: a relatively large, effective orifice area and its self-washing effect that prevents thrombus formation. There have been only a few reports of survivors with ball valve prostheses in place for more than three decades especially in the mitral position. This is a valuable report describing the long-term durability of a Smeloff-Cutter ball valve prosthesis in the mitral position.