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.