Seigo Gomi

Carotid and aortic screening for coronary artery bypass grafting

BACKGROUND To identify risk factors for preexisting carotid and aortic disease in coronary artery bypass grafting (CABG), preoperative parameters were analyzed. METHODS Three-hundred eight consecutive patients undergoing elective isolated CABG were investigated through preoperative duplex scanning of the carotid artery, computed tomography of the chest, and intraoperative ultrasonography of the ascending aorta. RESULTS Prevalence of carotid stenosis and ascending aortic atherosclerosis was 14.3% (44 of 308) and 30.2% (93 of 308), respectively. Multivariate analysis indicated that significant independent risk factors for carotid stenosis were atherosclerosis of the ascending aorta (p = 0.028, odds ratio [OR] = 2.16), peripheral vascular disease (p = 0.008, OR = 4.08), and history of stroke (p = 0.0004, OR = 3.73). Significant independent risk factors for ascending aortic atherosclerosis were peripheral vascular disease (p = 0.029, OR = 3.05), age older than 60 years (p = 0.009, OR = 2.94), and carotid stenosis (p = 0.018, OR = 2.27). Modifications on the operative procedure for aortic atherosclerosis were carried out in 49 patients. Overall hospital mortality and morbidity for stroke were 0.97% and 0.65%, respectively. CONCLUSIONS Prevalence of carotid and aortic disease was not low among candidates for CABG. Carotid and aortic screening may help to modify the operative strategy to reduce morbidity of stroke.

Acute heart failure due to local dehiscence of aortic wall at aortic valvular commissure

Spontaneous dehiscence of the aortic wall at the aortic commissure is not recognized as one of the usual pathological causes of aortic regurgitation. We describe the case of a 56-year-old man with hypertension, who experienced acutely progressive congestive heart failure due to massive aortic regurgitation. Local layer dehiscence around the commissure was noted with partial detachment of the commissure resulting in the loss of commissural support with secondary rupture of a non-coronary cusp, which led to massive aortic regurgitation.

Impact of immediate cerebral angiography for in-hospital cerebral thromboembolism after cardiovascular surgery

OBJECTIVES Postoperative stroke remains a serious problem in cardiovascular surgery. We studied the role of cerebral angiography in postcardiotomy stroke. METHODS We retrospectively analyzed 5 in-hospital patients with stroke due to cerebral thromboembolism after cardiovascular surgery. RESULTS The incidence of in-hospital cerebral thromboembolism was 0.5%, involving 5 patients among 913 adults undergoing cardiovascular operations. In-hospital cerebral thromboembolism occurred 3 to 9 days (average: 7 +/- 2 days) after surgery. Causes of cerebral thromboembolism were chronic atrial fibrillation in 1, transient atrial fibrillation in 2, artificial valve in 1, and intracranial arterial stenosis in 1. Immediate cerebral angiography, after exclusion of intracranial hemorrhage and complete cerebral infarction by computed tomography, revealed cerebral embolism in 3 and cerebral thrombosis in 2 with occlusion or stenosis of intracranial arteries. Local intraarterial administration of a thrombolytic agent was done in the 3 patients with cerebral embolism and occluded arteries were recanalized. Fibrinolysis was not done in 2 because of recanalized arteries or sufficient peripheral blood supply through collateral feeders. No patients exhibited rebleeding into the pericardial space or wound bleeding. All patients survived with moderate or full functional recovery. CONCLUSION Immediate cerebral angiography with/without local thrombolysis may improve functional outcome and survival in patients with postcardiotomy cerebral thromboembolism.

Pulmonary Atelectasis from a Posttraumatic Pseudoaneurysm of the Thoracic Aorta A Case Report and Review of the Literature

Atelectasis of the left lung due to tracheobronchial compression is a rare complication of posttraumatic pseudoaneurysms of the thoracic aorta. We describe the case of a 57-year-old man with a chronic posttraumatic pseudoaneurysm of the thoracic aorta with acute progressive dyspnea and complete atelectasis of the left lung. The patient underwent aneurysmectomy with an interposition of a Dacron graft using both median sternotomy and lateral thoracotomy. A diagnosis of posttraumatic aneurysm should be considered in patients with both acute left pulmonary atelectasis and a history of major chest trauma. A review of the literature regarding this clinical condition is also discussed.

Percutaneous vertebral angioplasty before coronary artery bypass grafting.

We report a case of a 63-year-old male with three-vessel coronary heart disease complicated by stenosis of the bilateral vertebral arteries. Triple coronary bypass grafting, using arterial conduits, was successfully performed after percutaneous balloon angioplasty of the left vertebral artery. Precedent angioplasty of a stenotic vertebral artery is safe and protects the brain from ischemia during extracorporeal circulation.

A Cause of Sudden Death: Rupture of Thoracic Aortic Aneurysm

Sudden death occurred during antihypertcnsive therapy of a Stanford type A dissecting aortic aneurysw. Hemodynamic and electrocardiograpbic events were recorded including deterioration of ventricular fibrillation 4 minutes after rupture.

Severe Hemolysis after Mitral Valve Plasty: A Case Report of Reoperation with Mitral Valve Replacement.

症例は78歳女性.6年前に僧帽弁閉鎖不全症に対し,他院にてDuranリング使用で弁形成術を受けた.2年前から労作時息切れが生じしだいに増悪した.僧帽弁閉鎖不全は中等度であったが,著明な貧血が進行し,血清ハプトグロビンの著明な減少とLDH上昇により,溶血性貧血と診断した.溶血は進行性でLDH2,000以上となり貧血と相まって臨床症状も悪化した.逆流する血流がリングやプレジェットなどの人工物に当たり溶血していると判断し,保存的に改善は不可能と考え再手術を行った.術中所見では,術前診断のとおりでリングの一部は組織から遊離し,内皮で覆われていなかった.25mmのCarpentier Edwards牛心嚢膜生体弁による弁置換術を行い,経過良好で退院し,溶血は消失した.僧帽弁閉鎖不全症に対する弁形成術後の再手術には,原疾患進行による閉鎖不全再発,高度溶血などの理由が報告されている.若干の文献的考察を加えて報告する.

Extended septoplasty for subaortic stenosis developed 19 years after double-outlet right ventricle repair

A 27-year-old woman developed subaortic stenosis 19 years after double-outlet right ventricle repair. Subaortic stenosis was caused by a narrow ring of fibromuscular ridge associated with a bulge of the underlying septal muscle. The aortic valve was bicuspid and stenotic. We conducted extended septoplasty, replacing the aortic valve. Postoperative cineangiogram showed an adequate left ventricular outflow pathway. Double-outlet right ventricle repair may thus be followed by subaortic stenosis as long as 19 years after initial surgery. This lesion was assumed due to acquired disease secondary to flow disturbances in the left ventricular outflow, so reconstructing an adequate outflow pathway is effective and appears to help avoid recurring stenosis.