Shunji Uchita

Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.

Anomalous subaortic left brachiocephalic vein (ASLBV) is a rare systemic venous anomaly. We review our experience with patients associated with ASLBV who underwent cardiac surgery at three institutions. From 1989 to 2009, the medical records of surgically treated patients with ASLBV were analyzed; the incidence of ASLBV, clinical characteristics, and associated anatomical findings were assessed. Fifteen patients had ASLBV. All ASLBVs coursed left lateral to the aortic arch, passed under the ascending aorta anterior to the central pulmonary artery, and joined the right brachiocephalic vein. Fourteen patients had congenital heart disease (CHD), and the remaining patient did not have cardiac anomalies. Its incidence was 0.57% (14 of 2,449) in patients with CHD and only 0.02% (1 of 4,805) in patients without CHD. In patients with CHD, 73.3% (11 of 15) of the patients had conotruncal cardiac anomalies such as tetralogy of Fallot, ventricular septal defect with pulmonary atresia, truncus arteriosus, and interruption of the aortic arch. Eight patients had aortic arch anomalies, including right aortic arch and cervical aortic arch. The deletion of chromosomal 22q11.2 was confirmed in two patients, and one patient was diagnosed with DiGeorge syndrome. ASLBV was clinically silent even without any surgical intervention. ASLBV is a very rare anomaly and is highly associated with conotruncal cardiac anomalies and aortic arch anomalies, including right aortic arch and cervical aortic arch. Preoperative diagnosis is important when any surgical interventions are intended, especially, in patients with conotruncal cardiac anomalies. Clin. Anat. 23:950–955, 2010.

Abrupt rupture of an aortic arch aneurysm into the pulmonary artery

We report an extremely rare case of pulmonary artery dissection caused by an abrupt rupture of an aortic arch aneurysm into the pulmonary artery. An asymptomatic 80-year-old man was admitted to our hospital for elective surgical repair of aortic arch aneurysm. After admission, sudden onset of hoarseness and dyspnea developed. Echocardiography demonstrated an intimal flap in the pulmonary artery and abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, the pulmonary artery dissection involved the main pulmonary artery and both major branches. Total arch replacement and pulmonary artery reconstruction were successfully performed.

Migration of the ringed ePTFE graft into the small intestine

A 78-year-old man who underwent coronary artery bypass surgery and mesenteric artery bypass surgery 6 months previously presented with a groin swelling. Occlusion of the celiac artery and severe stenosis of the superior and inferior mesenteric arteries had been detected before the coronary bypass. Two days after the coronary bypass, sudden bowel ischemia occurred. The visceral organs appeared to be free of necrotic changes, but the bowel was pale. As the patient needed immediate reperfusion of the bowel, we selected an artificial graft and chose to perform bypass grafting from the femoral artery to the superior mesenteric artery through the intraperitoneal free space. Therefore, emergency bypass surgery from the femoral artery to the superior mesenteric artery using a ringed expanded polytetrafluoroethylene graft (ePTFE) was performed (A/Cover). When the patient was admitted to our hospital 6 months after the operation, his left groin was swollen, and he had a low-grade fever. His appetite was very good, and there were no symptoms of panperitonitis. Emergency computed tomography revealed the occlusion of the ePTFE graft, air in the graft, and the migration of the graft into the small intestine (B and C) Cultures from the left groin grew Torulopsis glabrata and Escherichia coli, but blood cultures were negative. An urgent graft excision was performed. The graft was severely adhered to the sigmoid colon, and the body of the graft had perforated the small intestine (D). We removed the graft from the small intestine and found that it was filled with pus. After graft excision, the defects at the anastomotic site were patched with saphenous vein. Cultures of the artificial graft grew E. coli and Enterococcus faecalis. Antibiotics were administered for 2 weeks, and the infection was controlled well. This is a very rare case of the migration of an artificial graft into the small intestine. This case shows that bypass grafting from the femoral artery to the mesenteric artery through the intraperitoneal free space may cause the adhesion of the graft to the bowel and induce the perforation of the small intestine, and grafts should ideally be fixed to the retropertioneum.

Surgical management of patent ductus arteriosus in low body weight infants

Between January 1980 and December 1994, seventeen premature infants weighing less than 2500 g underwent surgical management for the isolated patent ductus arteriosus (PDA). Indometacine therapy for closure of PDA was not effective for all these patients. In terms of the body weight at birth, they were divided into two groups; Group I (G-I) consisted of ten patients with birth weight less than 1000 g and Group II (G-II) of seven patients weighing more than 1000 g. The age at operation was 22.1 +/- 15.4 days in the G-I and 14.3 +/- 11.4 days in the G-II. The ductus was ligated in all patients but one of the G-II, in whom it was divided. There were five (50%) hospital deaths in the G-I and none in the G-II. The causes of death in the G-I were related to necrotizing enterocolitis (NEC) in two and infant respiratory distress syndrome (IRDS), acute renal failure, and broncho-esophagial fistula in each. The age at operation tended to be older in nonsurvivors rather than in survivors in the G-I (28.0 +/- 16.8 days vs. 16.2 +/- 14.0 days, respectively, but the difference did not reach significance). Before surgery, all patients in the G-I required mechanical ventilator support and nine of them were associated with IRDS. In contrast, only two patients in the G-II needed mechanical ventilation preoperatively. The postoperative period of intubation was also significantly longer in the G-I than in the G-II (51.6 +/- 35.2 days vs. 2.2 +/- 1.5 days, respectively, p < 0.05). In conclusions, the surgery for PDA can be safely performed even in small premature babies weighing less than 1000 g. When medical therapy for PDA is not effective in the premature patients, the surgical management should be considered as early as possible before their conditions become worse due to such critical complications as NEC, IRDS, and renal failure.

Successful staged repair for a rare type of truncus arteriosus with interruption of the aortic arch and abnormal origin of the left coronary artery

We report a successful staged repair for a quite rare combination of truncus arteriosus (TA), Van Praagh type A4, and abnormal origin of the left coronary artery (CA). Furthermore, the case was complicated by a variant of the chromosomal anomaly in cat-cry syndrome. The presence of interruption of the aortic arch (IAA) and abnormal CA origin has been previously reported to increase mortality. To decrease the risk of bronchomalacia in infants, bilateral pulmonary artery banding (PAB) was performed as the first stage procedure for adjusting the pulmonary flow. Staged repair is a useful strategy for infants with complex TA.

Internal Thoracic Artery as an Abnormal Collateral Source to the Visceral Organs in Coronary Surgery

l I l t f T W l e p l e v t a i t t A 78-year-old man was admitted to our hospital with angina pectoris and multiple coronary risk factors. oronary angiography revealed severe coronary lesions nd an angiography of the left internal thoracic artery LITA) showed collateral arteries leading from the LITA o the visceral arteries (Fig 1). Evaluation of these collatrals using multi-slice computed tomography revealed otal occlusion of the celiac trunk (CT), as well as severe tenosis of the superior mesenteric artery (SMA), and the nferior mesenteric artery (IMA). Abnormal collateral irculation from the LITA to the CT through the muscuophrenic artery (MPA), left inferior phrenic artery LIPA), and left gastric artery (LGA) had developed along ith other collaterals leading from the right internal horacic artery (RITA) to the hepatic artery through the PA and the right inferior phrenic artery (RIPA) (Fig 2). ecause the symptoms of abdominal angina were absent, e performed isolated off-pump coronary artery bypass urgery with a radial graft to the left anterior descending oronary artery and saphenous vein grafts to the left ircumflex artery and right coronary artery. Two days

Twenty-six-year durability of an Ionescu–Shiley standard profile pericardial aortic valve

The Ionescu-Shiley pericardial valve (Shiley, Inc, Irvine, CA, USA) is a first generation bioprosthesis made from bovine pericardium. Despite its excellent hemodynamic performance, use of this prosthesis ceased because it had an unacceptably high rate of early structural deteriorations, especially in the era of the standard profile valve. We experienced a rare case of very long durability of an Ionescu-Shiley standard profile (ISSP) bioprosthesis.

Aortic Coarctation 28 Days after an Arterial Switch Operation in a Neonate.

Aortic coarctation rarely occurs after an arterial switch operation for D-transposition of the great arteries with intact ventricular septum. We report the case of a neonate patient in whom aortic coarctation developed 28 days after an uncomplicated arterial switch operation. Preoperatively, the aorta was noted to have an irregular shape, but there was no pressure gradient across the lesion. The patient underwent successful reoperation to correct the coarctation. We hope that our report raises awareness of a rare early complication after arterial switch operation with intact ventricular septum, and the need to carefully monitor the aortic isthmus in patients who have aortic irregularities, even in the absence of a pressure gradient.

Left ventricular ball-like thrombus after acute myocardial infarction with essential thrombocythemia

Left ventricular (LV) thrombus after acute myocardial infarction (AMI) is a frequent complication that is associated with a risk of systemic embolism. Essential thrombocythemia (ET) has opposing tendencies towards hemorrhage and thrombogenesis and it can cause AMI via thrombogenesis. Ball-like LV thrombus is associated with a high risk of systemic embolism. We describe surgical resection of LV ball-like thrombus from a patient with ET. A 60-year-old woman presented at our hospital with transient ischemic attack accompanied by transient hemiplegia. Ultrasonic cardiography revealed a mobile ball-like thrombus in the LV after transmural AMI of the anterior wall. We performed emergency LV thrombectomy because of the mobile LV thrombus with embolism. Platelet aberrations and pathological bone marrow findings were consistent with a diagnosis of ET. We administered the patient with anti-coagulation drugs and the DNA replication inhibitor hydroxycarbamide to decrease the platelet count. She continues to survive and is doing well without major postoperative complications. <Learning objective: Essential thrombocythemia (ET) can cause acute myocardial infarction with left ventricular (LV) thrombus via thrombogenesis. After we describe surgical resection of LV ball-like thrombus from a patient with ET, the patient was administered with anti-coagulation drugs and the DNA replication inhibitor hydroxycarbamide to decrease the platelet count. The patient continues to survive and is doing well without major postoperative complications.>.

A Rare Case of an Extracardiac Unruptured Aneurysm of the Sinus of Valsalva in a Patient With Single Coronary Artery

A 75-year-old man with gastric cancer underwent preoperative cardiac examination by echocardiography, and an unruptured extracardiac aneurysm was detected in the right sinus of Valsalva. Coronary angiography by multidetector computed tomography demonstrated a single left coronary artery. Patch closure of the orifice of the aneurysm of the right sinus of Valsalva was successfully performed for this extremely rare combination.