Optimal Tricuspid Annular Size for Tricuspid Annuloplasty in Patients with Less-Than-Moderate Functional Tricuspid Regurgitation

Background@#We evaluated the association between tricuspid annular dilatation and the development of moderate or severe tricuspid regurgitation (TR). Additionally, we determined the optimal tricuspid annular dilatation threshold to use as an indicator for tricuspid annuloplasty in patients with less-than-moderate functional TR (FTR). @*Methods@#Between August 2007 and December 2014, 227 patients with less-than-moderate TR underwent mitral valve surgery without a tricuspid valve (TV) procedure. The TV annular diameter was measured via transthoracic echocardiography. The TV annular index (TVAI) was calculated as the TV annular diameter divided by the body surface area.The mean duration of echocardiographic follow-up was 42.0 months (interquartile range, 9.3–66.6 months). @*Results@#Eight patients (3.5%) developed moderate or severe TR. The rate of freedom from development of moderate or severe TR at 5 years was 96.2%. TV annular diameter, left atrial diameter, preoperative atrial fibrillation, and TVAI were found to be associated with the development of moderate or severe TR in the univariate analysis. A cut-off TVAI value of 19.8 mm/㎡ was found to predict the development of moderate or severe TR, and a significant difference was observed in the development of TR of this severity based on this cut-off (p<0.001). @*Conclusion@#The progression of TR was not infrequent in patients with untreated lessthan-moderate FTR. An aggressive treatment approach can be helpful to prevent the progression of FTR for patients with risk factors, especially TVAI greater than 19.8 mm/m 2 .

Delayed Left Atrial Perforation Associated with Erosion After Device Closure of an Atrial Septal Defect

A 43-year-old man who had had a history of atrial septal defect (ASD) device closure 31 months previously presented with abrupt chest and back pain along with progressive cardiogenic shock and cardiac arrest. After resuscitation, he was diagnosed with cardiac tamponade. Diagnostic and therapeutic surgical exploration revealed left atrium (LA) perforation due to LA roof erosion from a deficient aortic rim. Device removal, primary repair of the LA perforation site, and ASD patch closure were performed successfully. The postoperative course was uneventful. The patient was discharged after 6 weeks of empirical antibiotic therapy without any other significant complications.

Persistent Fifth Aortic Arch with Coarctation

Persistent fifth aortic arch (PFAA) is a rare congenital anomaly of the aortic arch frequently associated with other cardiovascular anomalies, such as tetralogy of Fallot and aortic arch coarctation or interruption. We report the case of a neonate with PFAA with coarctation who successfully underwent surgical repair.

Change of Proximal Descending Aortic False Lumen after Conventional Repair of Acute Type I Dissection: Is It Always Unfavorable?

BACKGROUND: Some patients show favorable changes in the descending aortic false lumen after conventional repair of acute type A dissection, although the incidence of favorable changes has been reported to be low. We aimed to investigate the incidence of positive postoperative changes in the false lumen and the factors associated with positive outcomes. METHODS: In 63 patients who underwent surgery for type A acute dissection as well as serial computed tomography (CT) scanning, morphological parameters were compared between the preoperative, early postoperative (mean interval, 5.4 days), and late CT scans (mean interval, 31.0 months) at three levels of the descending thoracic aorta. RESULTS: In the early postoperative CT images, complete false lumen thrombosis and/or true lumen expansion at the proximal descending aorta was observed in 46% of the patients. In the late images, complete thrombosis or resolution of the proximal descending false lumen occurred in 42.9% of the patients. Multivariate analysis found that juxta-anastomotic false lumen thrombosis was predictive of favorable early changes, which were in turn predictive of continuing later improvement. CONCLUSION: Even after conventional repair without inserting a frozen elephant trunk, the proximal descending aortic false lumen showed positive remodeling in a substantial number of patients. We believe that the long-term prognosis of type A dissection can be improved by refining surgical technique, and particularly by avoiding large intimal tears at the anastomosis site during the initial repair.

Sternal Healing after Coronary Artery Bypass Grafting Using Bilateral Internal Thoracic Arteries: Assessment by Computed Tomography Scan

BACKGROUND: This study aimed to investigate sternal healing over time and the incidence of poor sternal healing in patients undergoing coronary artery bypass graft (CABG) surgery using bilateral internal thoracic arteries. MATERIALS AND METHODS: This study enrolled 197 patients who underwent isolated CABG using skeletonized bilateral internal thoracic arteries (sBITA) from 2006 through 2009. Postoperative computed tomography (CT) angiography was performed on all patients at monthly intervals for three to six months after surgery. In 108 patients, an additional CT study was performed 24 to 48 months after surgery. The axial CT images were used to score sternal fusion at the manubrium, the upper sternum, and the lower sternum. These scores were added to evaluate overall healing: a score of 0 to 1 reflected poor healing, a score of 2 to 4 was defined as fair healing, and a score of 5 to 6 indicated complete healing. Medical records were also retrospectively reviewed to identify perioperative variables associated with poor early sternal healing. RESULTS: Three to six months after surgery, the average total score of sternal healing was 2.07+/-1.52 and 68 patients (34.5%) showed poor healing. Poor healing was most frequently found in the manubrium, which was scored as zero in 72.6% of patients. In multivariate analysis, the factors associated with poor early healing were shorter post-surgery time, older age, diabetes mellitus, and postoperative renal dysfunction. In later CT images, the average sternal healing score improved to 5.88+/-0.38 and complete healing was observed in 98.2% of patients. CONCLUSION: Complete sternal healing takes more than three months after a median sternotomy for CABG using sBITA. Healing is most delayed in the manubrium.

Potts Shunt in Patients with Primary Pulmonary Hypertension

Idiopathic pulmonary arterial hypertension eventually leads to right-sided heart failure and sudden death. Its mortality rate in children is still high, despite improvements in pharmacological therapy, and therefore novel treatments are necessary. The Potts shunt, which creates an anastomosis between the left pulmonary artery and the descending aorta, has been proposed as a theoretically promising palliative surgical technique to decompress the right ventricle. We report the case of a 12-year-old girl with suprasystemic idiopathic pulmonary hypertension and right ventricular failure who underwent a Potts shunt for palliation with good short-term results.