Case Report
A 71-year-old man was referred to our hospital for dyspnea on exertion.
His medical history included type 2 diabetes mellitus, chronic renal
failure, right femoropopliteal bypass due to arteriosclerosis obliterans
(ASO), and CABG with LITA to LAD and saphenous vein graft (SVG) to the
left circumflex artery anastomoses 7 years previously. Cardiac
examination revealed a grade 3/4 systolic murmur in the auscultation
area of the aortic valve. The ankle–brachial pressure index in the
right and left leg was 0.87 and 0.70, respectively. Transthoracic
echocardiography (TTE) revealed a left ventricular ejection fraction of
70%, severe aortic stenosis with an aortic valve effective orifice area
of 0.9 cm2, transvalvular peak pressure gradient of 63
mmHg, and peak velocity of 4.0 m/s. Moreover, moderate aortic valve
regurgitation was observed. Hematological examination revealed
creatinine and blood urea nitrogen levels of 3.43 mg/dL and 71.0 mg/dL,
respectively. Contrast-enhanced computed tomography revealed patency of
the LITA to LAD and SVG to left circumflex artery anastomoses (Fig.1A),
calcification of the ascending aorta (Fig.1B), and that the ITA graft
was near the ascending aorta (Fig.2). Because of severe ASO, we decided
to cannulate the ascending aorta.
Surgery was performed via an upper partial re-sternotomy through an
approximately 8-cm inverted T-shaped incision in the fourth intercostal
space. After careful adhesiotomy around the right side of heart and
ascending aorta, LITA and SVG were secured without damage.
Cardiopulmonary bypass was established with cannulation of the ascending
aorta, superior vena cava and right atrium. An antegrade cardioplegia
line was inserted into the ascending aorta and a left ventricular vent
was placed through the right superior pulmonary vein. After aortic
cross-clamping and ITA and SVG clamping, cardiac arrest was achieved
using antegrade crystalloid cardioplegia. Additional cardioplegia was
selectively administered to the left coronary artery via a transverse
aortotomy. Next, the aortic valve leaflet with advanced calcification
was excised and a 19-mm Carpentier-Edwards Perimount Magna bioprosthesis
(Edwards Lifesciences, Irvine, California, United States of America) was
implanted in the supra- every noun.annular position (Fig 3). The total
bypass time, aorta cross-clamp time, and total operation time was 135
min, 90 min, and 310 min, respectively. The postoperative bleeding was
500 mL. The patient was weaned from the ventilator on the operative day
and discharged from the ICU on postoperative day 3. No complications
occurred, and the patient was discharged on postoperative day 17.
Postoperative TTE revealed a well-functioning prosthetic aortic valve
and LITA flow to LAD.