Mitsuru Akasaki

Emergency off-pump complete arterial revascularization in a patient with dextrocardia

We describe complete emergency arterial coronary artery bypass grafting performed on the beating heart of a 73-year-old man with situs inversus totalis and triple-vessel disease. The right internal mammary artery was anastomosed to the left anterior descending artery in situ. The first and second obtuse marginal branches of the circumflex coronary and the posterior descending branch of the right coronary artery were sequentially revascularized using the left internal mammary and radial arteries in situ. The only abnormality was that the position of the heart mirrored that of a normal heart. Beating heart surgery appears to be as safe in patients with dextrocardia as in the general population. However, the position of the surgeon must be reconsidered for optimal handling of stabilizers and to facilitate access to anastomosis sites. Understanding mirror-image coronary arterial anatomy is important for successful surgical outcomes among patients with dextrocardia.

Surgical treatment of multiple inflammatory aortic aneurysms of the aortic arch and thoracoabdominal aorta

A 67-year-old woman hospitalized with pleuritis was treated with antibiotics. Although the inflammation was resolved, saccular aneurysms in the aortic arch and thoracoabdominal aorta enlarged rapidly. We conducted graft replacement of the aortic arch, but despite careful blood pressure control, the thoracoabdominal aneurysm rapidly enlarged even further. We conducted graft replacement of the thoracoabdominal aorta on day 25 after the first operation. The postoperative course was uneventful and no exacerbation was found 18 months after the second operation. These multiple aortic aneurysms were diagnosed as inflammatory because bacterial tests of blood and aneurysmal walls were all negative and cells infiltrating aneurysmal walls were pathologically plasma cells.

Clinical studies on the vasodilating and anti-platelet effects of OP-41483, a prostacyclin derivative

The vasodilating and anti-platelet actions of OP-41483 was studied to determine the effective dose of this drug for the treatment of ischemic lower limbs. The compound was given to 11 patients intravenously at rates of 2.5, 5.0 and 10.0 ng/kg/min. Infusion at a rate of 10 ng/kg/min increased the mean flow rate of the tibial arteries from 3.15±1.77 ml/min before the infusion, to 7.89±2.51 ml/min (p<0.001) and to 6.38±3.19 ml/min (p<0.001), at the time of, and 60 minutes after the cessation of the infusion, respectively. The peripheral flow resistance of the tibial arteries was reduced from 2.1±1.12×105 dyne·sec/cm5 before the infusion to 0.9 ±0.33×105 dyne·sec/cm5 (p<0.001) and to 1.2±0.78×105 dyne·sec/cm5 (p<0.05), at the time of, and 60 minutes after the cessation of the infusion. ADP-induced platelet aggregation was reduced from 73.3±17.6% before the infusion to 50.7±24.5% (p<0.01) and to 64.0±23.5% (p<0.05), at the time of, and 60 minutes after the cessation of the infusion, respectively. Collageninduced platelet aggregation was also reduced from 71.4±24.0% to 66.6±21.5% before and after the infusion (p<0.05).

Acute aortic dissection associated with Sheehan's syndrome.

A 69-year-old woman with Sheehans syndrome who suffered acute Stanford type A aortic dissection had received corticosteroids and thyroid hormones for over 20 years. The entire ascending aorta was replaced in emergency graft replacement. We administered twice the usual dose of methylprednisolone during cardiopulmonary bypass and twice the patients usual dose of prednisolone from postoperative day 1 to 6. The usual 100 micrograms of levothyroxine sodium was given orally from postoperative day 1. The patients postoperative course was uneventful. This case emphasizes the importance of early active supplementary treatment with steroids and thyroid hormones for major surgery in patients with Sheehans syndrome.

Surgical Treatment of Traumatic Aneurysm of the Ascending Aorta

Traumatic aneurysm of the ascending aorta is a rare event. This case describes a patient with such an aneurysm, resulting from injuries received in a motorcycle accident. The patient was admitted to the emergency room of a local hospital complaining of chest pain, and was subsequently referred to our institution. On admission, a chest x-ray showed mediastinal widening. Computed tomography and aortography revealed an ascending aortic aneurysm and contusion of the upper lobe of the right lung. Due to concerns about bleeding from the lung contusion, surgery was delayed for one week. During surgery, intimal tears were detected at two sites in the ascending aorta. The wall of the ascending aorta was subsequently resected and a prosthetic graft inserted. The postoperative period was uneventful and a postoperative aortogram showed that the graft had molded well.

Successful surgical treatment of impending rupture of thoracoabdominal aortic aneurysm in an elderly patient with severe pulmonary emphysema

In a case of successful surgery for impending thoracoabdominal aortic aneurysmic rupture, an 83-year-old man with severe pulmonary emphysema was transferred to our hospital diagnosed with impending aneurysmic rupture. The aneurysm had been pointed out 2.5 years ago but surgical repair was not undertaken due to the patients severe pulmonary emphysema. After admission, computed tomography showed an enlarging saccular thoracoabdominal aortic aneurysm. Emergency surgery was conducted because of severe pain below the left costal margin. We resected the wall of the saccular aortic aneurysm and reconstructed the aorta with an on-lay patch under femoro-femoral bypass and selective visceral organ perfusion. Tracheostomy provided respiratory care on the day following surgery. The patient was weaned from respiratory support 6 days after surgery. Postoperative aortography showed that the reconstructed thoracoabdominal aorta functioned satisfactorily. The patient remains in good health 18 months after surgery.