Anterolateral Right Thoracotomy for Mitral Valve Replacement for Treating Infectious Endocarditis in a Case with Esophagus Reconstructed by Presternal Colonic Interposition for Previous Esophagogastrectomy

Rok vydání: 2008
Předmět:
Zdroj: Japanese Journal of Cardiovascular Surgery. 37:291-294
ISSN: 1883-4108
0285-1474
DOI: 10.4326/jjcvs.37.291
Popis: 約3年前に食道癌・胃癌に対し，食道・胃全摘術，左半結腸による胸骨前皮下食道再建術を施行された症例が，僧帽弁に逆流を認める感染性心内膜炎と診断された．右第四肋間開胸で僧帽弁置換術を施行し，良好な結果を得た．症例は77歳の男性であった．発熱，肉眼的血尿，食欲不振を主訴として来院し入院した．心エコーで IV度の僧帽弁逆流と診断され，血液培養で Streptococcus species が検出された． NYHA はIV度であったが，抗生剤で治療し，約1カ月後に僧帽弁置換術を施行した．胸骨正中切開は再建食道のため不可能で，右前側方開胸で手術を施行した．人工心肺の送血は右大腿動脈とし，脱血としては右大腿静脈から下大静脈まで脱血管を挿入し，右内頸静脈を皮膚切開で露出して上大静脈まで脱血管を挿入した．25℃まで全身を冷却し，心室細動下に右側左房切開で，僧帽弁を SJM 29mm人工弁で置換した．術中胸腔内には二酸化炭素を充満させた．加温後，直流除細動で心拍再開し，大動脈基部に心筋保護液注入管を挿入し，空気抜きを施行しながら人工心肺から離脱した．術後，覚醒時全身痙攣が見られたが一度で消失し，以後良好な経過であった． A case of infectious endocarditis was surgically treated by mitral valve replacement. The patient had previously undergone presternal subcutaneous colonic interposition as reconstruction surgery due to esophageal and gastric cancer. This artificial esophagus prevented the central sternotomy that is necessary for cardiac surgery. In cases where sternotomy is difficult, anterolateral right intercostal thoracotomy is useful. Arterial cannulation was performed via the femoral artery ; cannulations for venous drainage were performed in the femoral vein for the inferior vena cava and in the right jugular vein for the superior vena cava in order to establish cardiopulmonary bypass circulation. Under the condition of ventricular fibrillation and a body temperature of 25℃, the mitral valve that had been destroyed by infection was resected by exposure of the left atrium on its right side. An artificial Saint Jude Medical mechanical valve, 29mm in diameter, was implanted. The thorax was insufflated with carbon dioxide gas to prevent air embolization. An aortic vent tube was used for air drainage from the cardiac output. Although a seizure occurred once after the operation, the post-operative course was very stable ; currently, the patient (NYHA I) is in very good condition with no recurrence of the cancer.
Databáze: OpenAIRE
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