In patients with so-called porcelain aorta characterized by calcification of the total aorta, manipulation of the ascending aorta can cause cerebral infarction and other conditions due to aortic dissection or rupture and calcified debris. In the present case with ischemic cardiomyopathy and porcelain aorta, an occlusion balloon catheter was inserted into the ascending aorta to avoid its clamping, followed by Dor operation and CABG under cardiac arrest with normothermic extracorporeal circulation. Techniques such as deep hypothermic circulatory arrest and surgery while the heart is beating are often currently used as auxiliary methods to avoid aortic clamp. However, the present case with insufficient left ventricular function required a left ventriculotomy, and thus the technique presented here is useful for shortening the surgical time and ensuring a reliable outcome of the operation.
A 6-month-old baby boy had undergone the Jatene procedure at 4 days. Four months later, catheter intervention (balloon angioplasty) was performed because of severe stenosis at the bifurcation of the pulmonary arteries. Twenty days later, several episodes of cyanosis occurred and he was readmitted. The existence of shunt flow between the sinus of valsalva and the pulmonary bifurcation was detected by echocardiography and examination by 16-row MDCT revealed 2 holes at this site. Under a diagnosis of aortopulmonary (AP) window, the patient was placed on cardiopulmonary bypass and the pulmonary artery was opened after aortic clamping. There was a ridge between the bifurcation of the pulmonary arteries. After removing it, 2 holes were visualized that resembled the findings on 16-row MDCT. These holes were closed with Xenomedica patches and the main pulmonary artery was also extended with a Xenomedica patch. AP window is a rare complication after balloon angioplasty for pulmonary stenosis, but we must take great care to prevent this complication.
Several problems have been reported following coarctectomy, especially in cases involving longsegment coarctation COA . Although residual COA, proximal arch kinking, and airway compression may occur after coarctectomy, avoiding the use of artificial materials provides a better chance for the subsequent growth of the aorta. We successfully performed a modified end-to-end anastomosis with subclavian flap aortoplasty for a two-month-old boy with COA. A two-month-old boy was admitted to our hospital for nocturnal tachypnea and a feeding disorder. The initial echocardiography showed a preductal long COA beyond the left subclavian artery. A perimembranous VSD, a patent foramen ovale, and a patent ductus arteriosus were also noted. The left ventricular function was mildly depressed with an ejection fraction of 59%. Enhanced CT revealed a long-segment COA with a length of 15 mm. The blood pressure gradient between the upper and lower limbs was 40 mmHg. The operation was performed at the age of 2 months. The 4th intercostal space was opened through a posterolateral left thoracotomy incision. The distal end of the isthmus was so ligated as to maintain blood perfusion to the lower body through the PDA. The arch was clamped between the left carotid and the left subclavian artery LSCA . The LSCA and the isthmus were divided as distally as possible, and the two distal ends were longitudinally incised and sutured to each other in a side-to-side fashion using a 7 0 polypropylene continuous suture. After complete resection of the ductal tissue, a newly created distal arch was anastomosed to the descending aorta. The left ventricular ejection fraction was increased to 74% at discharge. Catheterizations 3 years after the surgery did not reveal any stenosis or deformity in the aorta at normal PA pressure. The patient has been doing well and is free of complications 7 years after the surgery. At present, end-to-end anastomosis and aortic arch advancement with or without cardiopulmonary bypass are widely used procedures for coarctectomy ; however, a modified end-to-end anastomosis is still a viable option for cases involving long-segment coarctation. Jpn. J. Cardiovasc. Surg. 46 : 66 69 2017 long-segment coarctation ; coarctectomy ; modified end-to-end anastomosis ; subclavian flap aortoplasty ; thoracotomy
A Successful Surgical Treatment of Ebsteinʼs Anomaly by Hetzerʼs Procedure in an AdultMitsutaka Nakao, Kiyozou Morita, Yoshihiro Ko, Takayuki Abe and Kazuhiro Hashimoto(Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan) A 29-year-old woman, who had been diagnosed with Ebsteinʼs anomaly associated with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White(WPW)syndrome, was referred to our hospital for treatment of congestive heart failure and tachycardia. She had undergone a catheter ablation for WPW syndrome at the age of 28 years. Subsequently, surgical treatment for Ebsteinʼs anomaly was indicated because of persistent symptoms of heart failure due to tricuspid regurgitation(TR). The echocardiogram and pathologic findings corresponded to Ebsteinʼs anomaly of the Carpentier type B classification, with severe displacement of the septal and posterior leaflets resulting in moderate TR. A mobile anterior leaflet of sufficient size without a cleft enabled us to successfully perform Hetzerʼs procedure. In this procedure, the large mobile anterior leaflet was approximated to the opposing true tricuspid annulus with a mattress suture of 3-0 polypropylene passed from the anterior leaflet annulus to the true tricuspid annulus at the site of atrialized right ventricle near the coronary sinus. The postoperative course was uneventful, and the cardiothoracic ratio reduced from 56% to 48% with mild TR. In this adult case of Carpentierʼs type B adult Ebsteinʼs anomaly, Hetzerʼs procedure allowed reconstruction of the tricuspid valve mechanism of "leaflet-to-septum" coaptation at the level of the true annulus by approximating the anterior leaflet. This was, effective in reducing the patientʼs moderate TR. We conclude that this procedure is a simple and reproducible method for repairing the tricuspid valve in Ebsteinʼs anomaly, especially for cases with a large mobile anterior leaflet.
A 59-year-old man has had a heart murmur for a long time. Four years previously coronary artery-pulmonary artery fistula was diagnosed as the cause of arrhythmia, by coronary angiogram. Despite two coil embolizations some fistulae recanalized and dilated. The coronary artery connected with the main pulmonary trunk and a part of plexiform angioma on the right ventricule outflow tract. Under heart beating, we ligated the origin of each fistulae with direct closure of the ostia from inside pulmonary artery.His symptoms finally improved.
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