Case of Unruptured Aneurysm of the Sinus of Valsalva into the Right Atrium with Perimembranous VSD / 日本心臓血管外科学会雑誌

An 8-year-old girl had been found to have a congenital ventricular septal defect (VSD), based on the presence of a cardiac murmur from birth. She had a history of infective endocarditis and lung abscess when she was 2 years old. Mild aortic regurgitation was revealed by an echocardiogram in August 2004. Right-heart catherization revealed a step up in the oxygen saturation of the right ventricle, aortography showed a deformity of the noncoronary cusp and mild aortic regurgitation, and Doppler color-flow echocardiography detected progression of aortic regurgitation. The patient underwent surgical repair of the VSD with a cardiopulmonary bypass. Following direct suturing combined with pledgets for perimembranous VSD, infusion of cardioplegia revealed the aneurysmal sac extruding from the wall of the right atrium. The final diagnosis was an aneurysm of the sinus of Valsalva from the noncoronary aortic sinus into the right atrium (type IV of Konno). The aneurysm was sutured by polyethylene strings with pledgets. The postoperative course was uneventful, and echocardiography performed before discharge showed no deformity of the sinus of Valsalva and trivial aortic regurgitation which was less than before surgery. She was discharged on the 7th postoperative day.

Determination of Entry Site for Acute Type A Aortic Dissection by Initial Enhanced CT-Scan / 日本心臓血管外科学会雑誌

Acute type A aortic dissection presents a surgical emergency because conservative therapy is not effective in the majority of instances. Enhanced CT-scan of the chest is commonly available and is considered to be an optimal diagnostic method for this disease. The operative strategy is to resect the primary tear to close the entry site of the aortic dissection and replace it with a tubular Dacron graft. Therefore, the existence of the entry site is important in determining the operative procedure. Based on the numerical value of the enhanced CT-scan inspection, the present study seeks to preoperatively identify the location of the presumed entry site in aortic dissection. From May 1996 to June 1999, 21 consecutive patients (Marfan's syndrome excluded) with acute type A aortic dissection underwent surgical treatment. Nineteen patients were preoperatively examined by enhanced CT-scan: 11 men and 8 women, with a mean age of 61 years. CT-scan slices used for early diagnosis were of the ascending aorta, aortic arch, descending aorta, and thoracoabdominal aorta. The largest diameters of the whole and true lumen were measured from cross-sectional aortic images with a personal computer, and the areas of the whole and true lumen were obtained by the manual tracing method. The true ratio was calculated for the largest diameter and area of the whole lumen. The nineteen patients were divided into two groups according to the location of the entry site based on the operating views. Seven patients with the entry site in the ascending aorta were classified as group A, and twelve patients with the entry site further in the aortic arch and descending aorta were classified as group B. Comparisons were performed by non-parametric analysis. Moreover, a discriminant analysis was applied to evaluate the classification between the two groups. The ratio of the largest diameter of the true lumen in group A at the level of the ascending and descending aorta was significantly greater than that in group B (75.0±11.3 vs. 59.7±14.0%, 82.7±8.6 vs. 70.1±11.4%). Linear discriminant analysis resulted in the correct classification rate of 68.2%, and 77.3%, respectively. The ratio of the area of the true lumen in group A at the level of the aortic arch was also significantly greater than in group B (65.4±17.3 vs. 45.7±15.8%) and linear discriminant analysis resulted in the correct classification rate of 55.1%, When the entry site was located in the aortic arch, the diameter of the true lumen was seen to be smaller in the ascending and descending aorta, and the dissecting lumen appeared enlarged. When the entry site is located in the ascending aorta, the ratio of the area of the true lumen in the aortic arch was significantly higher (55.1%). Detailed examination of enhanced CT-scans is useful to determine the location of the entry site and the treatment strategy for this disease.

A Case of Left Atrial Myxoma with Right Renal Infarction as an Initial Clinical Symptom / 日本心臓血管外科学会雑誌

We reported a case of left atrial myxoma with renal infarction as an initial clinical symptom. A 65-year-old man had severe right lumbago. A chest CT demonstrated right renal artery embolism. On emergency operation a right renal embolus was removed. Preoperative echocardiography and transesophageal echo showed a tumor in his left atrium which was close to the mitral valve. The tumor was resected one week after the first operation. Embolectomy of the right renal artery could not restore renal function. To the best of our knowledge, this type of cardiac myxoma with renal infarction as an initial clinical symptom is rare.

Operative Mortality and Long-Term Relative Survival Rate Following Surgery for Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

Surgery for abdominal aortic aneurysms (AAA, <i>n</i>=240) was reviewed in subgroups of ruptured AAA (RAAA, <i>n</i>=31), non-ruptured AAA with arteriosclerosis obliterans (AAA w/ASO, <i>n</i>=48), and non-ruptured AAA without ASO (AAA w/o ASO, <i>n</i>=161). The average follow-up period was 4.2 years (maximum 15.8 years) and the follow-up rate was 97%. Overall operative mortality rates were 41.9% in RAAA and 2.9% in non-ruptured AAA. Those were 6.3% in AAA w/ASO and 1.9% in AAA w/o ASO. The main causes of death in the long-term follow-up period were heart disease in 32%, malignant neoplasm in 22%, cerebrovascular accidents in 10% and renal failure in 10%, and miscellaneous. Only renal failure was related to operative risk factors. Relative survival rates excluding hospital death following surgery were 79% at 5 years and 0% at 10 years in RAAA; 74% at 5 years and 52% at 10 years in AAA w/o ASO; 95% at 5 years and 78% at 10 years in AAA w/ASO; 90% at 5 years and 70% at 10 years in non-ruptured AAA. These survival rates were lower than those found in the normal population, especially in AAA w/ASO. AAA w/ASO had more surgical risk factors of ischemic heart diseases and diabetes mellitus. Main causes of deaths were heart diseases, and renal failure during the long-term follow-up period was more predominant in AAA. It is important to follow all patients after surgery for AAA with special attention to heart disease and renal failure.

Pulmonary Valve Endocarditis Associated with Ventricular Septal Defect in an Infant / 日本心臓血管外科学会雑誌

A 2.5 year old male infant who had a ventricular septal defect and mild pulmonary stenosis was admitted for evaluation of fever and anemic complexion in February 1995. After admission, echo cardiography revealed massive vegetations from the outflow of the right ventricle to the right pulmonary artery through the pulmonary valve, and serial blood cultures were found to be positive for streptococcus mitis. Antibiotics did not relieve the high fever or decrease the volume of vegetation in the patient. At surgery, performed 2 weeks after the admission, the pulmonary valve was entirely destroyed and it was resected without prosthetic replacement after the excision of the vegetation and a Teflon patch was used for VSD closure. The post-operative course produced no noticeable complications. In the follow-up echocardiographic study, no vegetation was observed.