Résumé
<p>A 66-year-old man experiencing fever and dyspnea was transferred to our hospital 2 years ago. He had been on hemodialysis for 30 years due to chronic renal failure and was observed as having aortic stenosis for 5 years. Severe mitral regurgitation and complete atrioventricular block caused by infective endocarditis (IE) were noted. Thus, he emergently underwent double-valve replacement (DVR) and pacemaker implantation. The range of infection extended widely to the right atrium and atrioventricular septum beyond the mitral annulus. The infection was suppressed by perioperative antibiotic therapy. Transthoracic echocardiography (TTE) revealed a cavity approximately 30 mm in diameter in the left ventricle, which was located under the mitral annulus, and it extended to the right atrium 3 months after the operation. A diagnosis of left ventricular pseudoaneurysm associated with IE was then made. Because of progressive expansion of the aneurysm, we performed another operation 2 years after the previous one. The pseudoaneurysm was located in the region of the Koch's triangle, which indicated that it was caused by mitral annular abscess. We closed the orifice of the aneurysm approximately 20 mm in diameter with a polyester patch with a diameter of 35 mm. Postoperative TTE showed that the pseudoaneurysm was thrombosed and had no blood flow. Pathological examination of the wall of the pseudoaneurysm revealed that it consisted of fibrous tissues without myocardium. We encountered a rare case treated by patch closure for the left ventricular pseudoaneurysm after DVR associated with IE.</p>
Résumé
<p>A 55-year-old man presented with exertional dyspnea. He was found to have an incomplete atrioventricular septal defect (AVSD), mitral regurgitation, a patent foramen ovale (PFO), atrial fibrillation, and pectus excavatum. A one-stage operation including thoracoplasty in addition to the intracardiac repair was preferred in order to obtain a good view of the operative field and control the postoperative hemodynamics. Therefore, we performed autologous pericardial patch closure of the AVSD, mitral valve plasty with closure of the mitral cleft, direct closure of the PFO, and a modified maze procedure, followed by sternal elevation (modified Ravitch procedure) during chest closure. Postoperatively, his respiratory status on a respirator improved slowly and he was extubated on the 17th postoperative day. Dysphagia developed because of the prolonged intubation, but improved with deglutition rehabilitation. The subsequent postoperative course was uneventful and he was discharged on the 59th postoperative day. We performed a modified Ravitch procedure, instead of sternal turnover, because the latter requires exfoliating a broad area, which could increase the total blood loss and the risk of infection, and make it difficult to maintain the blood flow of the plastron. We obtained a good view of the operative field and stable hemodynamics postoperatively with sternal elevation in pectus excavatum accompanied by heart disease.</p>