Yuji Suda

Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach

BACKGROUND Off-pump coronary artery bypass grafting (OPCAB) can be performed in several ways using a minimally invasive approach (MIDCAB). Using the left anterior small thoracotomy (LAST) approach, only the LAD can be grafted. To expand the indications for MIDCAB from single-vessel disease to double-vessel disease, we have used a partial sternotomy without a transverse cut, namely, the lower-end sternal splitting (LESS) approach. Through this approach, the LAD and RCA can be revascularized by means of a single small incision without the risk of damaging the tissue around the intercostal space during harvesting of ITA when the sternum is transversely divided. The purpose of this study was to demonstrate the feasibility and safety of this technique. METHODS Between November 1999 and November 2000, a total of 22 patients underwent MIDCAB through a lower midline skin incision from the fourth intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without either a T- or reversed L-shaped division of the sternum. Of the patients, 14 had LAD disease only, 5 had both LAD and RCA disease, 2 had RCA disease only, and 1 had left main trunk disease. Two of the operations were of redo coronary artery bypass grafting. The mean age was 69.5 +/- 6.1 years (range 58 to 77 years). RESULTS The mean length of the skin incision was 8.5 +/- 1.4 cm (range 7 to 12 cm). No hospital death or morbidity was observed. All patients had arterial conduits: LIMA in 20 patients, RIMA in 3, RGEA in 4, and RA in 1. The mean number of grafts per patient was 1.3 +/- 0.6 (range 1 to 3). No blood transfusion was required perioperatively. The patency rate was 96%. All patients were in New York Heart Association class I and no wound complications or postoperative pain occurred during follow-up. CONCLUSIONS Our experience demonstrates that the LESS approach for MIDCAB is technically feasible for revascularizing not only the LAD but also the RCA system, with the same small incision using IMA and GEA. It can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude that this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD or RCA disease.

Tricuspid valve replacement after cardiac transplantation

Tricuspid regurgitation, a fairly common finding after cardiac transplantation, is generally mild or moderate, and is not clinically significant. The etiology of tricuspid regurgitation is not entirely understood, and experience with valve replacement after cardiac transplantation is limited. We describe a case of progressively severe tricuspid regurgitation ultimately requiring tricuspid valve replacement. At operation, the ruptured chordae of the posterior part of anterior and septal leaflet with resulting partially flail leaflets were found. Examination of the papillary muscle showed origins of several of the ruptured chordae. Damage to the tricuspid subvalvular apparatus at endomyocardial biopsy appeared to be a possible cause. A 31-mm Carpentier-Edwards porcine valve was implanted. This was because replacement with a mechanical prosthesis would prevent future right-side heart catheterization and endomyocardial biopsy and in valve repair, the patient remains exposed to the risk of the recurrence of chordal rupture. We discuss proposed causes and choices in surgical technique.

Coexistence of lung cancer and hamartoma

We present a rare case of a synchronous primary lung cancer adjacent to a hamartoma. A 71-year-old woman was admitted with congestive heart failure due to acute myocardial infarction. A chest radiogram on admission showed pulmonary edema with a tumor shadow in the right upper lung field. Because histological diagnosis was not obtained preoperatively, a wedge resection of the lung was conducted using video-assisted thoracoscopic surgery. The histopathological examination confirmed the coexistence of an adenocarcinoma with a chondromatous hamartoma. Right upper lobectomy was performed followed by excision of the mediastinal lymph nodes. Although hamartoma is generally considered to be a benign neoplasm, there have been several reports of increased risk to lung cancer in patients with a chondromatous hamartoma. Therefore, we recommend that patients with a hamartoma should be submitted to a complete evaluation and to regular follow-up, considering the risk to associated synchronous malignancy.

Twenty-two-year follow-up of saphenous vein grafts in pediatric Kawasaki disease

We describe 2 Kawasaki disease patients with excellent long-term patency of saphenous vein grafts, who underwent coronary artery bypass at age 7 and 9 years, respectively, and demonstrated normal growth during 22 years of follow-up. The grafts showed no deterioration and played an important role in coronary blood supply.

Lower sternal splitting approach for off-pump coronary artery bypass grafting

There are several ways to revascularize coronary arteries without cardiopulmonary bypass using a minimally invasive method. Currently, one of the most commonly used methods is minimally invasive direct coronary artery bypass (MIDCAB) through a left thoracotomy. Using this technique, however, only the left anterior descending and diagonal branch can be grafted. This article describes coronary revascularization of the left anterior descending artery or right coronary artery, or both, via a lower ministernotomy without a transverse cut, namely, the lower sternal splitting method. Through this approach, the left anterior descending, diagonal, and right coronary arteries can be revascularized using a single, minimally invasive approach without the risk of damaging the tissue around the intercostal space when the sternum is transversely divided.

Long-term results after Starr-Edwards mitral valve replacement in children aged 5 years or younger

BACKGROUND Mitral valve replacement with prosthetic valves in infants and children requires consideration of multiple variables. When we examined our late follow-up, the effect of the growth of the patient relative to the size of the prosthesis placed was the most important variable predicting late successful results. We reviewed our experience with mitral valve replacement using the Starr-Edwards ball valve in children aged 5 years or younger, focusing on the effect of valve prosthesis-patient mismatch on the long-term results in the growing patient. METHODS From August 1974 to June 1986, 8 patients aged 5 years or younger underwent mitral valve replacements using the Starr-Edwards prosthesis size OM in 3 patients and 1M in 5 patients. Model 6320 was used in 1 patient and Model 6120 in the remaining 7 patients. RESULTS Follow-up was 100% from 15 to 27 years (mean, 20 years). No valve-related complications of thromboembolism, anticoagulant-related hemorrhage, or prosthetic valve endocarditis were seen. All patients normally developed to adult size. The range of the valve area index of the 3 patients who received the smaller Starr-Edwards valve (size OM) was 0.97 to 1.24 cm2/m2. Although this size valve was adequate for patient growth to adolescence, in each case valve replacement with a larger valve was required. CONCLUSIONS Our long-term review of Starr-Edwards ball valve mitral valve replacement in children aged 5 years or younger shows that the Starr-Edwards ball valve (Models 6320 [1 patient] and 6120 [7 patients]) showed excellent durability, no thromboembolism, and no anticoagulant-related complications. Size OM valves required replacement for hemodynamic reasons because of patient growth; larger size 1M valves remained hemodynamically satisfactory in spite of patient growth.

Surgically treated aortic root aneurysm following aortic valve replacement.

A 65-year-old man with aortic regurgitation underwent aortic valve replacement with a St. Jude Medical prosthetic valve about 6 years ago. At that time, the aortic root was slightly dilated at about 40 mm in diameter and the ascending aorta was within the normal range. This year, the man was diagnosed with an aortic root aneurysm in regular follow-up echocardiography. Chest-enhanced computed tomography and chest aortography at our hospital demonstrated a pear-like aortic root aneurysm about 60 mm in diameter. Elective operation for the aortic root aneurysm was conducted September 29, 1999, based on the Bentall procedure. Composite graft replacement with coronary reconstruction was conducted using a 28-mm Hemashield prosthetic graft and a 23-mm St. Jude Medical prosthetic valve under cardiopulmonary bypass. An 8-mm Hemashield graft was interposed on the left main coronary artery and the right coronary artery was directly anastomosed using a Carrel patch method. The postoperative course was uneventful and post-operative examination demonstrated good surgical results. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. Surgical cases of aortic root aneurysm after aortic valve replacement are rare, but serious complications with the possibility of rupture or dissection warrant surgical intervention.

Starfish heart positioner and harmonic scalpel for redo off-pump coronary bypass.

In a redo off-pump coronary artery bypass operation through a repeat median sternotomy, use of the Starfish Heart Positioner in combination with the Harmonic Scalpel may facilitate dissection of adhesions without hemodynamic impairment.

Sealed Rupture of an Internal Iliac Artery Aneurysm in a 92-Year-Old Woman Surgically Treated with Success

症例は92歳,女性.下腹部痛と腰痛を主訴に前医を受診し,腹部大動脈瘤の疑いのため救急紹介された.CT検査で最大径85×73mmの右内腸骨動脈瘤を認め,切迫破裂が疑われた.腹部正中切開,経腹膜的アプローチで,緊急手術を施行した.後腹膜腔と腸間膜に血腫が認められ,sealed ruptureと考えられた.分岐型グラフト(Intergard 16×8mm)を用いて腹部大動脈人工血管置換術を行った.術当日に抜管し,術後2日目にICUを退室した.その後の経過も良好で,十分なリハビリののち,術後13日目に独歩で退院した.本症例は,検索しえた範囲内で,最高齢の内腸骨動脈瘤手術例であった.

Acute Aortic Dissection Occurring on the Day after Coronary Artery Bypass Operation

冠動脈バイパス術(CABG)術後の急性大動脈解離は希であるが重篤な合併症である.今回われわれは,CABGを施行した翌日に急性大動脈解離を発症し,緊急手術を行い救命しえた1例を経験したので報告する.症例は73歳,女性.狭心症のため,オフポンプCABG(3枝:RITA-LAD,LITA-OM,SV-PDA)を施行した.静脈グラフトの中枢側は上行大動脈に吻合した.術翌日,呼吸リハビリを行っていたときに,突然,著明な高血圧(200mmHg前後)となり,ほぼ同時に背部痛を訴えた.造影CT検査を行い,大動脈解離(Type A)と診断した.ただちに緊急手術で上行大動脈置換術を施行した.解離のエントリーは静脈グラフトの中枢側吻合部であった.術後経過は良好で,術後24日目に独歩で前医に転院となった.CABGのさいには,グラフトの中枢側吻合が大動脈解離の原因となり,かつ術後超急性期に発生しうることを知っておくべきである.