Regarding coronary artery bypass grafting (CABG) in patients on hemodialysis, in situ internal thoracic artery (ITA) grafting of the left anterior descending artery (LAD) improves survival and freedom from cardiac events. Although a problem with the ITA can possibly occur, using the ITA ipsilateral to an arteriovenous fistula (AVF) in the upper extremity of patients on hemodialysis can cause coronary subclavian steal syndrome (CSSS). CSSS is a condition of myocardial ischemia caused by the diversion of blood flow from the ITA following coronary artery bypass surgery. CSSS has been reported to occur in cases of subclavian artery stenosis, AVF, and low cardiac function.A 78-year-old man with end-stage renal disease experienced angina pectoris during hemodialysis. The patient was scheduled for CABG, including anastomosis of the left internal thoracic artery (LITA) and LAD. After completion of all anastomoses, the LAD graft demonstrated retrograde blood flow, suggestive of ITA anomalies or CSSS. The LITA graft was transected at the proximal part and anastomosed to the saphenous vein graft with sufficient flow to the high lateral branch eventually.
Infective endocarditis of the aortic valve tends to cause structural damage such as aortic root abscess, and aortic valve replacement is the standard treatment. However, there have been several reports on aortic valve repair for the treatment of infective endocarditis, and it has subsequently emerged as a feasible alternative to aortic valve replacement in selected patients. We report a case of aortic valve repair for infective endocarditis of the aortic valve caused by α-hemolytic Streptococcus. A 50-year-old man was admitted to our hospital with a two-month history of fever of unidentified origin. Transthoracic echocardiography revealed infective endocarditis of the aortic valve. Transesophageal echocardiography confirmed vegetation in the right coronary and non-coronary cusps, and mild aortic regurgitation. Although infection was controlled by approximately one month of antibiotic treatment, there was markedly more severe aortic regurgitation compared to the previous examination. These findings were confirmed on transesophageal echocardiography, and residual vegetation on the right coronary cusp as well as a perforation in the non-coronary cusp were confirmed. Intraoperative findings revealed a perforation in the non-coronary cusp and dehiscence, with vegetation on the right coronary cusp. The vegetation was carefully removed, the non-coronary cusp perforation was repaired with a pericardium patch, and the defect on the right coronary cusp was directly sutured with 6 0 polypropylene. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation. The postoperative course was uneventful and the patient was discharged 7 days after surgery without any complications. Antibiotics were prescribed for 3 months, and transthoracic echocardiography was performed 5 days, 1 month, and 3 months after surgery. No evidence of recurrence of aortic regurgitation or infection of the aortic valve was observed.
Man‐in‐the‐barrel syndrome (MIBS) is characterized by weakness in the bilateral upper‐extremity muscles with relatively preserved strength in the face and lower‐extremity muscles. We present a case of MIBS‐like symptoms due to spinal cord infarction caused by transient hypoperfusion in the left ascending cervical artery (ACA) secondary to Stanford type A acute aortic dissection. To identify the ACA as the responsible artery, ischemic change by MRI of the longus colli muscle, which is primarily supplied by the ACA, was effective.
A 64-year-old man on dialysis presented to the emergency department with a fever and chills. Transthoracic echocardiography (TTE) showed small vegetation on the posterior mitral leaflet (PML). Antibiotic therapy was initiated. Two weeks later, right hemiparesis occurred. MRI of the head showed occlusion of the left middle cerebral artery, which suggested an embolism derived from the vegetation. The patient was then referred to the department of cardiovascular surgery. Transesophageal echocardiography (TEE) revealed perforation of the PML and severe mitral regurgitation (MR). The patient underwent mitral valve repair. The postoperative course was uneventful, and the patient was discharged after six weeks of antibiotic treatment. A fresh autologous pericardium is the material of choice to repair the valve.
We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest lowest bladder temperature : 21.9. The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70 mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90 mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.
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