A Case of Surgical Repair for End-Stage Tricuspid Regurgitation with Severe Liver Dysfunction and Hepatic Encephalopathy / 日本心臓血管外科学会雑誌

We report the case of a patient with severe tricuspid regurgitation and severe liver dysfunction who was successfully treated by tricuspid valve repair with spiral suspension and perioperative management of high cardiac output. The patient was a 77-year-old woman who presented with chronic atrial fibrillation with bradycardia (heart rate approximately 50 bpm). She had been diagnosed with severe tricuspid valve and mitral valve regurgitation at the age of 74. As her heart failure and hepatic failure grew worse, and hepatic encephalopathy also occurred, she was admitted to the hospital. Her Child-Pugh score for liver disease was Grade C at the preoperative assessment, suggesting that she was in the high-risk category for open heart surgery. Therefore, further medical treatment was required before selecting the surgical treatment. After the implantation of a pacemaker (VVI mode, 80 bpm), the cardiac output increased with a cardiac index of 5.17 L/min/m2 compared with 2.97 L/min/m2 prior to pacemaker implantation. Furthermore, the symptoms of heart failure improved and total bilirubin decreased from 3.9 mg/dl to 1.7 mg/dl, and surgery was performed. Tricuspid regurgitation was treated with spiral suspension, and mitral regurgitation due to annular dilation was treated with annuloplasty. Following the surgery, the cardiac index was maintained from 4.3 L/min/m2 to 5.8 L/min/m2 with central venous pressure below 10 mmHg by the assistance of intra-aortic balloon pumping. The patient was extubated 30 h after surgery, and was discharged on postoperative day 54. At the time of discharge, total bilirubin was 1.5 mg/dl. At 1.5 post-operative years, the patient is New York Heart Association functional Class II and tricuspid valve regurgitation is mild.

A Case of Thoracic Endovascular Aortic Repair for Subacute Aortic Dissection Stanford Type B in a Patient with Marfan Syndrome / 日本心臓血管外科学会雑誌

A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

A Case Report of Ductus Arteriosus Aneurysm in an Adult with Non-specific Inflammatory Response / 日本心臓血管外科学会雑誌

A 24-year-old man was admitted to another hospital due to fever and chest and back pain. Enhanced chest computed tomography showed an aneurysm between the distal aortic arch and left pulmonary artery. The patient was transferred to our hospital for surgery. Because of suspicion of an infectious ductus arteriosus aneurysm, antibiotic therapy was started. Urgent graft replacement of the descending aorta was performed on the third day due to the enlargement of the aneurysm. All blood cultures including the preoperative examination, and the aneurysmal culture were negative. The histopathological study showed non-specific inflammatory response with plasma cell, T lymphocyte, and B lymphocyte infiltrations. There was no evidence of infection. Eventually we diagnosed this patient as having a ductus arteriosus aneurysm with non-specific inflammation. The antibiotic therapy was terminated on postoperative day 10, and the postoperative course was uneventful.

Hemolytic Anemia due to Left Ventricular to Right Atrium Communication after Tricuspid Annuloplasty / 日本心臓血管外科学会雑誌

<p>An 82-year-old man was referred to our hospital for heart failure due to severe mitral regurgitation and severe tricuspid regurgitation. We performed mitral annuloplasty and tricuspid annuloplasty (TAP). Three weeks after surgery, he developed hemolytic anemia (HA). Transesophageal echocardiography revealed a defect in the left ventricular outflow tract that communicated directly with right atrium, and the jet was striking with the TAP prosthetic ring. HA was not controlled, so we performed re-operation. The defect was found in the atrioventricular membranous septum. The defect was closed and TAP was performed using an autologous pericardial roll again. We report a rare case of acquired left ventricular to right atrium communication after TAP.</p>

Lung Metastasis of Renal Cell Carcinoma Extended into the Left Atrium / 日本心臓血管外科学会雑誌

We report an extremely rare case of renal cell carcinoma (RCC) extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.

Effects of wearing graduated elastic compression stockings on arterial stiffness / 体力科学

This study aimed to determine the effects of wearing graduated elastic compression stockings (GCSs) on arterial stiffness. The study included 10 healthy men who were randomly assigned to undergo trials with and without GCSs on separate days. Baseline measurements of brachial-ankle pulse wave velocity (baPWV), heart rate, and brachial blood pressure (BP) were obtained in the supine position after the subjects had rested for 20 min without GCSs. The order of the trials (with or without GCSs) was set randomly. During both trials, data for these parameters were collected with the subjects in the supine position, after they had rested for 20 min. After both trials, the brachial BP did not significantly change from the baseline values. baPWV significantly decreased after trials with GCSs (from 1153.0 ± 123.4 to 1078.1 ± 134.3 cm/s, P < 0.05), but no significant difference was observed after trials without GCSs (from 1125.2 ± 118.7 to 1134.5 ± 100.9 cm/s). In addition, changes in volume after trials with GCSs (-74.9 ± 35.3 cm/s) were significantly lower than those after trials without GCSs (+9.3 ± 36.7 cm/s, P < 0.05). baPWV significantly decreased during supine rest on wearing GCSs. This decrease in baPWV was possibly caused by a decrease in arterial stiffness itself and/or a decrease in vascular transmural pressure that may have been due to increase in external pressure on the vasculature.

A Case of Refractory Sustained Ventricular Tachycardia with Dilated-Phase Hypertrophic Cardiomyopathy Treated by Left Ventriculotomy / 日本心臓血管外科学会雑誌

A 63-year-old man had been receiving medical treatment for hypertrophic cardiomyopathy (HCM) for 20 years. Sustained ventricular tachycardia (VT) had often occurred over the previous 2 years in spite of the administration of antiarrhythmic drugs. He therefore received an implantable cardioverter defibrillator (ICD). However, his symptoms did not improve thus dilated-phase HCM was diagnosed. Because sustained VT often occurred subsequently, the ICD had to be frequently used. An electrophysiological study (EPS) using the CARTO electroanatomical mapping system revealed the earliest activation site to be in the posterolateral wall of the left ventricle (LV). VT did not stop despite 2 endocardial catheter ablation procedures. Therefore, the VT foci was thought to be a reentry circuit on the epicardial side of the posterolateral LV wall. A part of the posterolateral LV wall that involved the reentry circuit was therefore resected. Since undergoing this surgical procedure, the patient has experienced no recurrence of VT during a follow-up period of 14 months.

Simultaneous Cardiac Resynchronization Therapy and Mitral Valve Replacement in a Patient with Dilated Cardiomyopathy / 日本心臓血管外科学会雑誌

We performed cardiac resynchronization therapy (CRT) in addition to mitral valve replacement (MVR) in a 66-year-old patient with dilated cardiomyopathy (DCM) associated with complete left bundle branch block (CLBBB) and mitral valve insufficiency. Tissue Doppler echocardiography showed synchronicity of the septum and lateral wall in the left ventricle after CRT. New York Heart Association functional class improved from III to I after CRT and MVR. CRT of the dyssynchronic myocardium in a patient with DCM associated with CLBBB improves regional cardiac function and synchronicity.

Simultaneous Cardiac Resynchronization Therapy and Cardiac Surgery in a Patient with Complete Right Bundle Branch Block (CRBBB), Left Posterior Hemiblock (LPH), and Aortic Valve Insufficiency / 日本心臓血管外科学会雑誌

We performed cardiac resynchronization therapy (CRT) in addition to aortic valve replacement (AVR) in a 74-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 15%), complete right bundle branch block (CRBBB), left posterior hemiblock (LPH), and aortic valve insufficiency. Tissue Doppler echocardiography showed synchronicity of the septum and posterior segments in the left ventricle, and that contraction of the septum was in the systolic phase of the cardiac cycle after CRT. The New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in a patient with CRBBB and LPH can improve regional cardiac function and synchronicity.

THE HIGHER CALF PRESSURE INDUCED BY WEARING GRADUATED ELASTIC COMPRESSION STOCKING INCREASES CALF VENOUS COMPLIANCE / 体力科学

The purpose of the present study was to clarify effect of increase in calf pressure on calf venous compliance. The calf pressures were increased by wearing elastic compression stockings with different pressures (Calf pressure 0, 12, 17, 21 mmHg). Healthy twelve people (six men and six women, 43.3±15.3 years) volunteered to participate in this study. Changes in calf venous volume during spine rest were measured by mercury plethysmography. We analyzed the calf venous compliance by inflating the venous collecting cuff to 60 mmHg for 7 min, then decreasing cuff pressure at 1 mmHg/sec (over 1 min) to 0 mmHg, using cuff pressure as an estimate of venous pressure. This method produced pressure-volume curves fitting the quadratic regression (Δlimb volume)=β₀+β₁·(cuff pressure)+β₂·(cuff pressure)², where Δ is change. The higher calf venous compliance and volume were observed in with the higher pressure stocking. These results suggest that higher calf pressure induced by wearing elastic compression stocking increases calf venous compliance and maximum venous outflow.

A Case of the Senning Procedure in a Patient with Transposition of the Great Arteries with Intact Ventricular Septum and Bicuspid Pulmonary Valvular Stenosis Associated with Pulmonary Hypertension / 日本心臓血管外科学会雑誌

We performed the Senning operation and pulmonary valvotomy in an 11-month-old baby with transposition of the great arteries (TGA) with an intact ventricular septum (IVS), and bicuspid pulmonary valvular stenosis associated with pulmonary hypertension (PH). Preoperative catheterization showed a pressure gradient (PG) between the left ventricle (LV) and main pulmonary artery (MPA) of 35mmHg, mean pulmonary artery pressure (MPAP) of 56mmHg, and pulmonary vascular resistance (PVR) of 11.2unit·m². The pure oxygen inhalation test showed a decrease in MPAP from 56 to 38mmHg, and a decrease in PVR from 11.2 to 5.5 unit·m². We could not perform lung biopsy to determine the surgical indications in terms of PH due to preoperative progressive congestive heart failure in this patient. Postoperative catheterization (28 days after the Senning operation) showed a decrease in PG between the LV and MPA to 8mmHg, and MPAP also decreased to 17mmHg. Two radical operations were possible in this patient. One was the arterial switch operation (ASO), and the other was the atrial switch operation, i. e. the Senning or the Mustard operation. We selected the Senning operation because there was the possibility that the new aortic valve might develop persistent stenosis and regurgitation after ASO and pulmonary valvotomy. The Senning operation may be an alternative in selected patients with TGA with IVS and pulmonary valvular stenosis.

Simultaneous Cardiac Resynchronization Therapy and Cardiac Surgery in a Patient with Triple Coronary Vessel Disease, Mitral and Tricuspid Valve Insufficiency after Three-Area Old Myocardial Infarction / 日本心臓血管外科学会雑誌

We performed cardiac resynchronization therapy (CRT) in addition to coronary artery bypass grafting (CABG), mitral valve replacement (MVR) and tricuspid valve annuloplasty (TAP) in a 72-year-old patient with poor cardiac function (New York Heart Association functional class III, ejection fraction 38%), triple coronary vessel disease, and mitral and tricuspid valve insufficiency after three-area old myocardial infarction. Electrocardiography showed no change in the QRS interval after CRT. However, tissue Doppler echocardiography showed synchronicity of the septum and posterior segments in the left ventricle, and that contraction of the septum was in the systolic phase of the cardiac cycle after CRT. New York Heart Association functional class improved from III to I after the operation. CRT of the dyssynchronized myocardium in which ischemia and volume overload were improved by CABG, MVR and TAP may improve regional cardiac function and synchronicity.