Tomokazu Kosuga

Stroke in thoracic aortic surgery: outcome and risk factors.

The risk factors and the outcome of stroke in thoracic aortic surgery were studied in 127 patients (86 males, 41 females), aged 18 to 84 years (mean, 64 years), operated on between September 1994 and December 2000. There were 29 operations on the ascending aorta, 63 arch, 29 descending, 5 thoracoabdominal, and 1 extraanatomical bypass. Perioperative stroke occurred in 15 patients (12%). The risk factors for stroke were identified as preexisting chronic renal failure and femoral arterial cannulation. Hospital death occurred in 4 of the 15 cases (27%) of stroke and 7 of the 112 cases (6%) without stroke (p < 0.05). There were 18 late deaths during a mean follow-up period of 3.2 years (range, 1 month to 7.2 years). The 3-year survival rates were 43 ± 14% in the stroke patients and 85 ± 4% in the other patients. Actuarial survival, including during hospitalization, was lower in the stroke patients than in the other patients not only among those 70 years or older but also among all the patients (both p < 0.0001). Stroke occurring in thoracic aortic surgery is thus an important risk factor for early and late mortality, particularly in patients 70 years or older.

Spontaneous rupture of the spleen caused by a Bacillus infection: Report of a case

We report a case of spontaneous splenic rupture (SSR) caused by a Bacillus species (sp.) infection. A 36-year-old man on warfarin therapy since an aortic valve replacement at the age of 13 was admitted to our hospital with a 3-week history of a high fever. He had been asymptomatic until 4 months previously, when he suffered a cerebral embolism despite adequate oral anticoagulation. Abdominal computed tomography revealed splenic infarctions, which resulted in splenic rupture 2 days later. After embolization of the splenic artery, splenectomy was successfully performed. Pathologic examination revealed splenic infarction, resulting from septic emboli, with associated rupture of the splenic capsule, but no abscess was found. Bacillus sp. was isolated from cultures of arterial blood preoperatively, and the excised splenic specimens, postoperatively. In addition to rupture of the suppurating intrasplenic vessels with hematoma formation, the anticoagulant therapy possibly contributed to distension of the intrasplenic hematoma.

Atrial Septal Aneurysm Associated With Mitral Valve Disease

trial septal aneurysm is an infrequent anomaly that is often accompanied by other cardiac anomalies or ystemic thrombosis. A 63-year-old woman presented with decreased exerise tolerance for approximately 7 months. The patient ad a history of cerebral embolism 1 year previously. uscultation revealed an accentuated first sound, diatolic rumble, and opening snap at the apex. Transthoacic echocardiography demonstrated an atrial septal neurysm (26 20 mm) bulging to the right atrium and he thickened, stenotic mitral valve. The aneurysm was learly delineated as a thin, localized bulging of the atrial eptum that protruded into the right atrium by transsophageal echocardiography; however, no intracardiac

Multidirectional computed tomography for the left sinus of Valsalva aneurysm with aortic regurgitation.

A 46-year-old man had a left sinus of Valsalva aneurysm (Fig. 1, Video 1) and severe aortic regurgitation. Multidirectional computed tomography scan clearly demonstrated the anatomical relationship among the aneurysm orifice, aortic annulus and left coronary artery orifice (Fig. 2, Video 2). He underwent patch closure of the sinus of Valsalva aneurysm and aortic valve replacement. www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 37 (2010) 952

Emergent surgery for 3 aged patients who refused elective operation for thoracic aortic aneurysm

This report describes 3 aged patients undergoing emergent surgery who refused elective operation for a thoracic aortic aneurysm because of freedom from symptoms attributable to the aneurysm at the time of presentation. A 77-year-old woman with a thoracoabdominal aneurysm 57 mm in diameter at presentation had recurrent hemoptysis 12 months later. A 78-year-old man with a saccular type distal arch aneurysm 64 mm in diameter at presentation was transported with shock and hemothorax 27 months later. Another 82-year-old man with a saccular type distal arch aneurysm 60 mm in diameter at presentation was admitted with severe chest and back pain 36 months later. All of them underwent tube graft replacements of the aneurysm urgently and were discharged on foot. Aged patients with life-threatening events should not be denied surgical intervention because of excessive operative mortality and morbidity, even if they had previously refused elective surgery.

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: Report of two cases

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a cardiac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative.

Early results with the Carbo-seal composite valve conduit for aortic root replacement: Comparison with the St. Jude Medical/Hemashield composite graft

The Carbo-seal (C-S) composite valve conduit incorporates the CarboMedics mechanical prosthetic aortic valve in a gelatin-impregnated, twill-woven Gelweave tube graft. We evaluated the early results of the C-S composite graft in patients undergoing elective aortic root replacement. Five aortic root replacements with the C-S were compared with nine similar surgeries with St. Jude Medical/Hemashield (S-H) composite grafts, which were assembled during surgery. Both the Gelweave and the Hemashield graft fabrics are relatively thin and soft, allowing improved needle passage and surgical manipulation. No device-related complication was observed in the C-S group, although one low-output syndrome due to poor cardiac protection was found. In the S-H group, a non-infectious fever and a pleural effusion were observed. Body temperatures in both groups recovered to less than 37°C within 3 days after operation. The two groups demonstrated similar time courses in CRP, white blood cell count, red blood cell count, and LDH and no statistically significant intergroup differences. In terms of valve function (peak velocity and pressure gradient were determined by Doppler echo cardiography), both types of valves have remained within normal range through the last routine examination. Graft dilation also remained within an acceptable range at 6 months after operation, with no significant intergroup differences. In conclusion, the initial results indicated that the C-S composite valve conduit is a reliable device for use in aortic root replacement and may be considered comparable to the S-H. A longer follow-up in a larger patient population is necessary to confirm this positive early result.

A Case of Unruptured Aneurysm of the Sinus of Valsalva.

症例は36歳女性. 5歳時に心室中隔欠損症 (VSD) の診断を受け経過観察中であった. 36歳時, 労作時の軽度の息切れと動悸を認めるようになったことから精査目的のため, 当科紹介となった. 心エコー検査では肺動脈弁直下に直径約1cmのVSDを認めたが, バルサルバ洞の瘤状の突出像は確認できなかった. 右室造影像では肺動脈弁直下の右室流出路に, 円形で大きさが1.0cm×1.5cmの陰影欠損を認め非破裂性バルサルバ洞動脈瘤 (今野分類I型) と診断し手術を施行した. 術後経過は良好で術後14日目の左室造影検査ではVSDは完全に閉鎖されバルサルバ洞動脈瘤もまったく造影されなかった. また, 診断には右室造影検査が有用であった.