Two Cases of Left Ventricular Outflow Tract Obstruction after Rastelli Type Operation for Cardiac Anomalies Associated with Transposed Aorta from the Right Ventricle / 日本心臓血管外科学会雑誌

Intracardiac repair for cardiac anomalies associated with a transposed aorta from the right ventricle is a technically demanding operation. We present two cases of left ventricular outflow tract (LVOT) obstruction after the use of an ePTFE flat patch to reconstruct the LVOT. Case 1 : A 10-year-old boy had undergone the Rastelli operation, VSD enlargement, and intraventricular re-routing using an ePTFE flat patch for repair of the DORV with noncommitted VSD and pulmonary stenosis at the age of 5. Five years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using a part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. Case 2 : A 13-year-old girl had undergone a double-switch operation (Senning operation, the Rastelli operation, and intraventricular re-routing by the use of an ePTFE flat patch) for the repair of corrected TGA, PA and VSD at the age of 7. Six years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. We consider that the use of a flat patch for reconstruction of a left ventricular out flow tract in cases with transposition of the aorta from the right ventricle involves a risk of future development of LVOT obstruction.

Right Ventricular Outflow Obstruction due to Huge Un-ruptured Aneurysm of the Sinus of Valsalva in Two Elderly Patients / 日本心臓血管外科学会雑誌

A sinus of Valsalva aneurysm is a comparatively rare disease, and it has almost no symptoms unless this is rupture, whereas aortic insufficiency, myocardial ischemia and heart failure might be associated with un-ruptured aneurysm of the sinus of Valsalva. We encountered 2 elderly patients (71 years old and 83 years old) with huge un-ruptured aneurysm of the sinus of Valsalva which causes right ventricular outflow tract obstruction. The orifice of the aneurysm of the sinus of Valsalva was closed using ePTFE patches in the both cases. Plication of aneurysm was attempted in both cases, but it failed in case 1 due to undetermined border of the aneurysm on the right side of the heart. Case 2 was required concomitant aortic valve replacement with a bioprosthesis due to associated aortic regurgitation. The repair of un-ruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract obstruction can be performed safely and effectively even in elderly patients.

Left Ventricular Outflow Pseudoaneurysm after Aortic Valve Replacement for Active Infective Endocarditis / 日本心臓血管外科学会雑誌

A 56-year-old man, who underwent aortic valve replacement with a stentless artificial valve for aortic valve endocarditis at age 52, found to have left ventricular outflow pseudoaneurysm by transthorasic echocardiography, transesophageal echocardiography and enhanced computed tomography. We repaired the pseudoaneurysm, combined with valve re-replacement. Left ventricular outflow pseudoaneurysm is a rare disease, and is often associated with active endocarditis. Transesophageal echocardiography and CT scan are useful to diagnose this disease, especially to rule out annular abscess. Operative indication is recommended soon after the diagnosis was made to prevent rupture of pseudoaneurysm, or development of either mitral regurgitation or coronary ischemia due to compression from the pseudoaneurysm. Combined aortic valve replacement, with or without mitral valve replacement is necessary to repair the pseudoaneurysm.

A Patient Who Underwent Mitral Annuloplasty for Mitral-Valve Insufficiency due to Calcification of the Mitral-Valve Annulus / 日本心臓血管外科学会雑誌

A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.

Two Cases of Aortic Regurgitation with Dove-coo Murmur: Operative Findings of the Valves / 日本心臓血管外科学会雑誌

We describe two cases of aortic regurgitation with dove-coo murmur that required aortic valve replacements. In the first case, there were three small perforations of the cusps, two in the noncoronary cusp and one in the right coronary cusp. The cause of the cusp perforations was unclear. In the second case, there were two perforations of the cusps, one in the left coronary cusp and another small one in the right coronary cusp, along with a subannular pseudoaneurysm. The cause of the cusp perforations was an infective endocarditis. Before 1955, aortic regurgitations with dove-coo murmur were mostly reported to be originated by retroversion of the valve cusps due to syphilis. After 1960, syphilis was replaced by various diseases that bring about perforations, tears and retroversions of the cusps. The condition which is concerned in the development of the dove-coo murmur is that the aortic valve cusps have lesions without calcification and preserve the flexibility.