Valve-Sparing Excision of Multiple Papillary Fibroelastomas in the Aortic Valve and Left Ventricular Outflow Tract / 日本心臓血管外科学会雑誌

Primary cardiac fibroelastoma is a relatively rare tumor and is often detected incidentally by echocardiography. We report a case of multiple fibroelastomas that were found incidentally by follow-up echocardiography for hypertrophic cardiomyopathy and were treated with valve-sparing excision. The patient was a 71-year-old man, in whom a 10-mm tumor on the ventricular septum below the right coronary cusp and 3-mm tumors on the left ventricular side of the left and right coronary cusps were detected. Although he had no symptoms, because the tumors were mobile, surgery was performed for preventing embolization and making a definitive diagnosis. The tumor on the ventricular septum was excised together with the surrounding endocardium and part of the myocardium. The tumors on the valve leaflets were excised with the aortic valve cusps spared. Histopathologically, all the tumors were fibroelastomas. The postoperative course was uneventful.

Hemolytic Anemia after Mitral Valve Surgery / 日本心臓血管外科学会雑誌

<b>Objective</b> : The aim of this study is to describe a series of patients undergoing reoperation due to hemolytic anemia after mitral valve surgery and assess the mechanisms and surgical outcomes. <b>Methods</b> : Between 2009 and 2014, we performed redo mitral valve surgery in 11 patients who had refractory hemolytic anemia after mitral valve surgery at Kyoto University Hospital. The mean age of the patients was 72.2±6.8 years old, and there were 5 men. <b>Results</b> : Preoperative echocardiography demonstrated that only 3 patients had ≥ grade 3 mitral regurgitation (MR), the rest of the patients had only mild to moderate MR. The mechanisms of severe hemolysis included paravalvular leakage (PVL) after mitral valve replacement (MVR) in 8 patients, structural valve deterioration (SVD) after MVR using a bioprosthesis in one, and residual/recurrent mitral regurgitation after mitral valve plasty (MVP) in two. All the patients except one (re-MVP) underwent MVR. The mean interval between previous operation and current operation was 14.1±9.4 years in post-MVR cases, and 2.0±1.9 years in post-MVP cases. There were three late deaths, one of which was due to cardiac death (exacerbation of heart failure due to pneumonia). There was one patient who required re-MVR for recurrent hemolysis due to PVL after MVR. <b>Conclusion</b> : Although hemolytic anemia after mitral valve surgery is rare, it often requires reoperation regardless of the degree of MR at late follow-up period. Thus, patients after mitral valve surgery should be carefully followed-up.

A Case of Right Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum / 日本心臓血管外科学会雑誌

A 60-year-old man was referred to our hospital for surgical treatment of sinus of Valsalva aneurysm and aortic regurgitation. He had suffered from palpitation and leg edema since a month before. Echocardiography revealed right sinus of Valsalva aneurysm dissecting into interventricular septum complicated with aortic and mitral regurgitation. He successfully underwent patch closure of aneurysm, aortic valve replacement and ring annuloplasty of mitral and tricuspid valve. His postoperative course was uneventful.

Merits and Demerits of the Reversed Elephant Trunk Technique Based on Experiences with 6 Cases / 日本心臓血管外科学会雑誌

We encountered 6 cases of descending or thoracoabdominal aortic aneurysm operation with reversed elephant trunk (R-ET). R-ET was originally developed by Dr. Carrel in order to circumvent the dissection of the proximal anastomotic site from surrounding organs such as the lung, recurrent nerve, phrenic nerve, and esophagus in the future proximal aortic replacement. Three of 6 patients underwent a 2nd operation (total arch replacement). Distal anastomosis was easy and safe. One patient had multiple cerebral infarction and died after the second operation, but no patient suffered from complications derived from injury to the lung, esophagus, recurrent nerve or phrenic nerve. During outpatient follow-up, 1 patient who had suffered from paraparesis after the 1st operation died of repture of an arch aneurysm before the 2nd operation could be. Thrombosis was found between the inside and outside grafts of R-ET in 2 patients, who had been implanted with Gelweave prosthesis. There were no negative events caused by the thrombus. One patient with the thrombus underwent total arch replacement. We removed the fibrin-like thrombus from the R-ET prosthesis under endoscopic visualization without any complication. R-ET is a very easy and useful technique, but one should exert care about the thrombus formation around the R-ET.

A Case of Heparin-Induced Thrombocytopenia (HIT) with Postoperative Cerebral Infarction Following Surgical Repair of Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

A 61-year-old man with consciousness disorder was transferred to our hospital. Computed tomography found acute type A aortic dissection and cardiac tamponade, and an emergency operation was performed. Operation findings indicated dissection above the commissure between the left coronary cusp and the right coronary cusp, to the ostium of the right coronary. An ascending aorta replacement and coronary aorta bypass grafting were performed. The postoperative course was good, but he did not regain clear consciousness. Results of magnetic resonance imaging showed multiple cerebral infarctions. At the same time, the platelet count had decreased and we suspected heparin-induced thrombocytopenia (HIT). Following detection of an heparin-dependent antibody, administration of an heparin was discontinued. However, the platelet count still tended to decrease. Therefore, we started continuous administration of argatroban, which resulted in the gradual increase in platelet count to within normal limits on postoperative day 26. The results indicate that in patients continuously and repeatedly treated with heparin, there is a possibility of the development of HIT and thrombosis with HIT.