Case 1
A 65-year-old woman presented with dyspnea on exertion. She had undergone aortic valve replacement (AVR) for aortic valve stenosis 2 years ago. The patient had a history of diabetes mellitus (on insulin lispro, 10-12-14-0 U; insulin detemir, 0-0-0-10 U per day) with onset at 55 years of age. Additionally, she had been undergoing hemodialysis since she was 58 years old, due to chronic renal failure with diabetic nephropathy. She also had hypothyroidism, secondary hyperparathyroidism, and sleep apnea; she never smoked. Her father had suffered from chronic renal failure and her mother had a malignant lymphoma. In this case, the inflammatory response decreased immediately after the first operation and remained low and stable, with C-reactive protein levels remaining between 0.1 and 0.5 mg/dL until the second operation.
The patient was admitted to our hospital because she noticed a decrease in her blood pressure during dialysis and dyspnea over the last 2 months with worsening of symptoms. On echocardiography, the left ventricular ejection fraction (LVEF) was found to have dropped sharply from 73 to 40% (New York Heart Association class III). Her height and weight were 151.8 cm and 63.3 kg, respectively. Her blood pressure was 88/50 mmHg, and her heart rate was 77 bpm (normal sinus rhythm). The laboratory data were as follows: hemoglobin, 14.3 g/dL; platelet count, 159 × 109 /L; total protein, 6.9 mg/dL; albumin, 3.5 mg/dL; triglyceride, 105 mg/dL; low-density lipoprotein (LDL) cholesterol, 87 mg/dL; HDL-cholesterol, 32 mg/dL; serum-calcium (Ca), 9.6 mg/dL; serum phosphorus (P), 6.7 mg/dL; hemoglobin A1c (HbA1c), 5.2%; and brain natriuretic peptide (BNP), 2914 pg/mL.
Her oral medications included sucroferric oxyhydroxide (1500 mg/day), precipitated calcium carbonate (1500 mg/day), cinacalcet hydrochloride (12.5 mg/day), bisoprolol fumarate (2.5 mg/day), levothyroxine sodium hydrate (50 µg/day), linagliptin (5 mg/day), miglitol (100 mg/day), and pitavastatin calcium hydrate (2 mg/day). Electrocardiogram (ECG) revealed normal sinus rhythm and ST depression in V4-V6 (Fig. 1). Chest radiography revealed a cardiothoracic ratio (CTR) of 57%, and CT revealed a severely calcified coronary artery (Fig. 2). Ultrasonic echocardiography (UCG) after AVR revealed an effective orifice area of 1.2 cm2. She had moderate mitral regurgitation with a right ventricular pressure (RVP) of 66 mmHg. UCG indicated poor left ventricular function (left ventricular end-diastolic dimension (LVDd)/left ventricular internal dimension in systole: 48/38 mm, LVEF 40%) and hypokinesis in the anterior and posterior walls.
Two years previously, cineangiography had revealed 25% stenosis in the left main trunk (LMT) and the proximal left anterior descending artery (LAD); however, at admission, it revealed 99% stenosis in the LMT, 100% occlusion in the proximal LAD, and 99% stenosis in the proximal left circumflex artery (LCX) (Fig. 3a, b). During AVR, myocardial protection was provided using antegrade/retrograde perfusion, but not directly by selective perfusion in each coronary artery. We inserted an intra-aortic balloon pump (IABP) preoperatively and performed emergency surgery (Euro II risk score, 61.7%; STS risk score, 56.3%).
We performed sternotomy as was performed during AVR. After adhesion detachment, an artificial cardiopulmonary bypass (CPB) was established, with the inflow in the ascending aorta and the outflow in the right atrium. We performed coronary artery bypass grafting (CABG) (left internal thoracic artery [LITA] to LAD and saphenous vein graft to the left posterolateral branch [PL]), mitral annuloplasty (MAP) with a 26-mm CG Future (Medtronic plc, Dublin, Ireland), and tricuspid annuloplasty (TAP) with a 28-mm Contour 3D ring (Medtronic plc). The duration of overall surgery, CPB, and aortic cross-clamping was 393, 202, and 153 min, respectively. We removed IABP on the fourth postoperative day and postoperative ventilator management was completed on the fifth postoperative day. She stayed in the intensive care unit (ICU) for 13 days and was discharged on postoperative day 21. She was able to enjoy her daily routine life 1 year after the surgery, and her LVEF had improved from 40 to 55%.
Case 2
A 78-year-old man presented with dyspnea on exertion. He had undergone resection of a left atrial myxoma 4 years prior to admission. He had a history of diabetes mellitus with onset at the age of 60; at the age of 71, he started undergoing dialysis for chronic renal failure due to diabetic nephropathy. He also had hypertension, hyperlipidemia, hypothyroidism, and secondary hyperparathyroidism, and was undergoing radiation therapy for prostate cancer. He had never smoked and his family history was unremarkable. He became aware of dyspnea on exertion in the previous 2 months, and was admitted to our hospital because his condition worsened. UCG revealed that the LVEF had decreased sharply from 73 to 44% (New York Heart Association class III). In this case, the inflammatory response remained low and stable at C-reactive protein levels of 0.3 to 0.5 mg/dL until the second operation.
His height and weight were 170.0 cm and 64.4 kg, respectively. His blood pressure was 86/48 mmHg and heart rate was 70 bpm (normal sinus rhythm). His laboratory data were as follows: hemoglobin, 10.2 g/dL; platelet count, 132 × 109/L; total protein, 5.7 mg/dL; albumin, 3.3 mg/dL; triglycerides, 54 mg/dL; LDL-cholesterol, 44 mg/dL; HDL-cholesterol, 44 mg/dL; Ca, 8.1 mg/dL; P, 3.1 mg/dL; HbA1c, 7.0%; and BNP, 3461 pg/mL. His oral medications included aspirin (100 mg/day), furosemide (20 mg/day), carvedilol (2.5 mg/day), lansoprazole (15 mg/day), precipitated calcium carbonate (3000 mg/day), rosuvastatin calcium (5 mg/day), and nicorandil (15 mg/day).
ECG revealed normal sinus rhythm with Q waves in leads II, III, and aVF, and ST segment depression in V5-V6 (Fig. 4). Chest radiography and CT revealed a CTR of 72% and severe calcified coronary arteries (Fig. 5). UCG revealed poor left ventricular function (LVDd/Ds, 56/43 mm; LVEF, 44%; inferoposterior wall hypokinesis; and mild MR with RVP of 29 mmHg). Cineangiography 4 years ago had shown only 25% stenosis in the proximal LAD; at admission, it revealed 90% stenosis in the same proximal LAD, 99% stenosis in the proximal LCX, and 95% stenosis in the posterolateral branch (PL) of LCX (Fig. 6a, b). He had low blood pressure during dialysis and underwent emergency surgery (Euro II risk score 40.7%; STS risk score, 33.2%).
We performed a sternotomy similar to the one performed previously, and then performed CABG (LITA-LAD, and LITA-right internal thoracic artery [right internal thoracic artery, RITA-Diagonal branch-PL1-PL-2-PL3]). The duration of surgery and CPB was 514 and 172 min, respectively. The postoperative ventilator management was completed in 9 h. He stayed in the postoperative ICU for 4 days and was discharged on postoperative day 10. The LVEF had improved from 44 to 50%, and all grafts were well patent (Fig. 7).