Successful concomitant minimally invasive surgery for aortic valve stenosis and right lung cancer via right mini-thoracotomy : A case report.

BACKGROUND: The case of aortic valve stenosis complicated with lung cancer have compelled cardiovascular surgeons to make challenging. We report the first successful short-term outcomes of one-stage minimally invasive aortic valve replacement and video-assisted thoracoscopic surgery lobectomy through right mini-thoracotomy in a patient with synchronous bicuspid severe aortic valve stenosis which was unsuitable for transcatheter aortic valve implantation and right lung cancer. CASE PRESENTATION: A 76-year-old man with severe aortic valve stenosis was diagnosed with lung cancer of the right upper lobe with stage IA2. Considering the potential risk of tumor metastasis, a one-stage surgical therapy for right lung cancer and type 0 bicuspid aortic valve stenosis was required; however, transcatheter aortic valve implantation was unsuitable due to a bicuspid aortic valve with severe calcification. Therefore, concomitant minimally invasive aortic valve replacement and lobectomy via right mini-thoracotomy were performed. The postoperative course was uneventful. CONCLUSION: Concomitant aortic valve replacement and right lobectomy via right mini-thoracotomy may reduce surgical invasiveness, leading to early recovery. This surgical strategy is a useful option, particularly for patients with aortic valve stenosis complicated with right lung cancer.

Towards a Clinical Implementation of Measuring the Elastic Modulus of the Aorta From Cardiac Computed Tomography Images.

OBJECTIVE: The elasticity of the aortic wall varies depending on age, vessel location, and the presence of aortic diseases. Noninvasive measurement will be a powerful tool to understand the mechanical state of the aorta in a living human body. This study aimed to determine the elastic modulus of the aorta using computed tomography images. METHODS: We constructed our original formulae based on mechanics of materials. Then, we performed computed tomography scans of a silicon rubber tube by applying four pressure conditions to the lumen. The segment elastic modulus was calculated from the scanned images using our formulae. The actual modulus was measured using a tensile loading test for comparison. RESULTS: The segment moduli of elasticity from the images were 0.525 [0.524, 0.527], 0.524 [0.520, 0.524], 0.520 [0.515, 0.523], and 0.522 [0.516, 0.532] (unit: MPa, median [25%, 75% quantiles]) for the four pressure conditions, respectively. The corresponding measurements in the tensile test were 0.548 [0.539, 0.566], 0.535 [0.528, 0.553], 0.526 [0.513, 0.543], and 0.523 [0.508, 0.530], respectively. These results indicated errors of 4.2%, 2.1%, 1.1%, and 0.2%, respectively. CONCLUSION: Our formulae provided good estimations of the segment elastic moduli of a silicon rubber tube under physiological pressure conditions using the computed tomography images. SIGNIFICANCE: In addition to the elasticity, the formulae provide the strain energy as well. These properties can be better predictors of aortic diseases. The formulae consist of clinical parameters commonly used in medical settings (pressure, diameter, and wall thickness).

Endovascular Aneurysm Repair for a Patient with Horseshoe Kidney and the Importance of Watershed Sign and Volumetry by Preoperative Contrast-Enhanced Computed Tomography.

We report a case of endovascular aneurysm repair (EVAR) in a patient with horseshoe kidney (HSK) in whom preoperative contrast-enhanced (CE) computed tomography (CT) showed watershed sign. This sign enabled prediction of postoperative renal function by accurate renal volumetry. A 75-year-old man with HSK and a 59-mm abdominal aortic aneurysm was referred for treatment. Preoperative CECT showed watershed lines at the margin of the isthmus, which was perfused by the accessory renal arteries. Using this sign, we calculated the accurate volume of the isthmus, which was 24.5% of the total parenchyma. EVAR was safely performed without renal dysfunction.

Infective calcified amorphous tumor on mitral valve and critical course of left ventricular rupture.

Calcified amorphous tumor is a rare intracavitary cardiac lesion and an accompanying infection is extremely rare. A 76-year-old woman was transferred to our hospital because of cerebral infarction. Echocardiography and chest computed tomography showed a calcified large mobile mass on the posterior mitral valve that was diagnosed with a calcified amorphous tumor. Moderate aortic regurgitation and severe mitral regurgitation were also confirmed. Her blood culture detected Gamella sp. We surgically dissected this infective calcified amorphous tumor. The border between this infective tumor and the mitral annulus was unclear because of severe infection and necrotic tissue. After careful complete resection, the healthy ventricular muscle was exposed and we performed annular reconstruction with bovine pericardial patches. And we replaced the aortic and mitral valves using bioprosthesis. While weaning from cardiopulmonary bypass, however, left ventricular rupture occurred twice. Despite successful repair of left ventricular rupture, which controlled bleeding, she died from multi-organ failure on postoperative day 6. An infective calcified amorphous tumor in such a critical case has not been reported previously. The calcified amorphous tumor probably become serious when the infection occurred. In this situation, the utmost caution should be paid to the patient. .

Minimally invasive surgical repair for unroofed coronary sinus syndrome directed by three-dimensional transesophageal echocardiography.

BACKGROUND: The recent remarkable development of cardiac imaging technology for unroofed coronary sinus syndrome has led to accurate preoperative diagnosis. We report a case of unroofed coronary sinus syndrome repaired via a minimally invasive approach, under the excellent command of three-dimensional transesophageal echocardiography. CASE PRESENTATION: A 77-year-old woman with hypertension was admitted for aggravation of bilateral leg edema and diagnosed with type III unroofed coronary sinus syndrome with Qp/Qs ratio of 1.6:1. The unroofed portion was detected at the atrial side between P2 and P3 of posterior mitral leaflet by preoperative three-dimensional transesophageal echocardiography. Right minithoracotomy was performed at the fourth intercostal space and cardiopulmonary bypass routinely established. Right atriotomy and left atriotomy incisions were made under antegrade cardioplegic arrest. The unroofed portion was revealed at the same location by preoperative transesophageal echocardiography and was clearly recognized only by endoscopy, not by direct vision. It was repaired by direct running suture under endoscopic visualization. We observed no blood cardioplegia leakage or mitral insufficiency, which was also confirmed by postoperative transesophageal echocardiography. The patient's postoperative course was uneventful and she was discharged home 14 days after surgery without any residual shunt. CONCLUSIONS: Successful repair of unroofed coronary sinus syndrome was safely and effectively achieved by a minimally invasive approach supported by preoperative three-dimensional transesophageal echocardiography.

[Tips for Use of Chordal Guide System for Easy Adjustment of Appropriate Artificial Chordae Length in Patients Undergoing Minimally Invasive Mitral Valve Repair].

OBJECTIVES: In patients who require minimally invasive mitral valve repair (MICS-mitral), it is difficult to determine the appropriate length of artificial chordae, position, and number of artificial chordae. The Memo 3D Rechord, a complete prosthetic ring associated with a temporary chordal guide system comprised of yellow loops that function as a reference guide for automatically determining the height of neo-chordae. We sought to evaluate our tips for use of this system. METHODS: Five patients (1 male, mean 68 years old) who underwent MICS-mitral using artificial chordae with the Memo 3D Rechord were evaluated. Prior to surgery, we assessed the prolapse position using 3-dimensional( 3D) echocardiography to decide the number and positions of the artificial chordae. Polytetrafluoroethylene (PTFE) sutures were passed through the papillary muscles and the free margin of the prolapsed leaflet, then appropriate positioning of the PTFE chordae was performed using a saline test. The PTFE chordae were passed through the loops and the free margin of the prolapsed leaflet was brought to the posterior annulus. Then, the PTFE sutures were tied and the temporary loop system removed. RESULTS: All patients had posterior leaflet prolapse. The number of the artificial chordae was 2 in 3 patients, and 1 in 2. The base of the artificial chordae was attached to the anterior papillary muscle in 3patients and posterior in 4. Additional indentation closure was required in 1 patient. All mitral valve repairs were performed successfully. Postoperative echocardiography mitral regurgitation( MR) grade was trivial in 5. CONCLUSIONS: Using our technique, it was possible to decide the appropriate length and position of the artificial chordae and MICS-mitral for leaflet prolapse with the Memo 3D Rechord is a simple and reproducible method.

Aortic valve replacement with annular patch enlargement for a patient with Werner's syndrome and severe aortic stenosis.

BACKGROUND: Werner's syndrome is an autosomal recessive rare genetic disorder characterized by clinical features suggestive of accelerated aging caused by mutation of the WRN gene. Although some reports exist of aortic valve replacement for aortic stenosis in patients with Werner's syndrome, case using annular patch enlargement for a small aortic annulus are rare. We report herein the rare case of a patient with Werner's syndrome and severe aortic stenosis treated by aortic valve replacement with annular patch enlargement. CASE PRESENTATION: A 55-year-old woman genetically diagnosed with Werner's syndrome suffered from symptomatic severe aortic stenosis with small annulus. Elective aortic valve replacement was performed. Intraoperatively the aortic annulus measured < 16 mm in diameter. Nicks technique for aortic root enlargement using a Hemashield patch was performed and an 18-mm mechanical valve was successfully inserted. After being discharged home her postoperative course was satisfactory for 2 years. CONCLUSIONS: Aortic valve replacement with annular patch enlargement to treat a small aortic annulus in a patient with Werner's syndrome was successful. Treatment strategy must be determined while considering of the patient's age, physical status, and severity of complications.

Impact of stroke volume on severe aortic stenosis in patients with normal left ventricular function.

BACKGROUND: Low-flow (LF) aortic stenosis (AS) with a normal ejection fraction reportedly has a worse prognosis than normal-flow (NF) AS. We assessed whether the stroke volume affects early- and long-term survival of patients with AS undergoing aortic valve replacement. METHODS AND RESULTS: From 2007 to 2016, 179 patients with AS and a normal ejection fraction (≥ 50%) and without other valve diseases were divided into two groups according to the stroke volume index (SVI): NF group (SVI ≥ 35 ml/m2, n = 167) and LF group (SVI < 35 ml/m2, n = 12). Early- and long-term survival was compared between the two groups. Preoperative echocardiography showed that the end-diastolic diameter and aortic valve area were smaller in the LF than NF group (43 ± 1.9 vs. 48 ± 0.4 mm, p < 0.005 and 0.33 ± 0.14 vs. 0.49 ± 0.14 cm2/m2, p < 0.0005, respectively). Hospital mortality was significantly higher (16.7% vs. 1.8%, p < 0.05) and 5-year overall survival was lower (58 ± 17 vs. 84 ± 4.2 months, p < 0.005) in the LF than NF group. CONCLUSION: Patients with LF AS had worse operative and long-term outcomes than those with NF, even though they had preserved LV function.

Left ventricular outflow tract obstruction masked by severe aortic stenosis.

An 81-year-old woman developed severe hemolytic anemia after aortic valve replacement. The anemia was not caused by paravalvular leakage, as in most cases. Instead, it occurred secondary to left ventricular outflow tract obstruction that had not been seen preoperatively and was induced by afterload reduction following aortic valve replacement. The hemolytic anemia was drug-refractory and finally treated with dual-chamber pacing, as for hypertrophic cardiomyopathy.

Functional independence measure for elderly patients undergoing aortic valve replacement.

OBJECTIVE: This study aimed to evaluate the efficacy of the Functional Independence Measure to assess preoperative frailty for elderly patients undergoing surgical aortic valve replacement. METHODS: Eighty-five patients >65 years who survived elective isolated aortic valve replacement from January 2008 to October 2015 were included. The mean age at the operation was 78 ± 6 years old (n = 28 males, n = 57 females). The patients were divided into two groups according to their status at discharge: impossible to discharge home or hospitalization for >30 days (compromised group, n = 8), or unaffected (unaffected group, n = 77). Preoperative frailty was evaluated with the Functional Independence Measure, which comprises 18 items divided into six domains: self-care, sphincter control, mobility, locomotion, communication, and social cognition. RESULTS: The preoperative total Functional Independence Measure score was significantly lower in the compromised group (79 ± 32) than in the unaffected group (120 ± 9, p < 0.01). The preoperative motor Functional Independence Measure score was significantly lower in the compromised group (45 ± 24) than in the unaffected group (85 ± 9, p = <0.01). The duration of postoperative intubation, intensive care unit stay, and postoperative hospitalization were significantly longer in the compromised group than in the unaffected group (48 ± 67 vs 16 ± 12 h, p < 0.01; 6.7 ± 5.3 vs 3.4 ± 2.0 days, p < 0.01; 34 ± 27 vs 23 ± 11 days, p = 0.02, respectively). CONCLUSIONS: The preoperative Functional Independence Measure is effective for assessing preoperative frailty in elderly patients undergoing aortic valve replacement in terms of predicting operative morbidity.

Endovascular Aortic Arch Repair with Mini-Cardiopulmonary Bypass to Prevent Stroke.

Debranching thoracic endovascular aortic repair for aortic arch pathology is an important alternative to total arch replacement. However, the problem of intraoperative stroke due to atherosclerotic changes in the aorta remains. We apply our minimally invasive mini-cardiopulmonary bypass system to prevent intraoperative stroke during the endovascular procedure. Once debranching from the right axillary artery to the left common carotid and the left axillary artery is constructed; only the brachiocephalic artery is a pathway to the brain. After mini-cardiopulmonary bypass using the debranching graft is established, all cerebral perfusions are not only maintained, but retrograde blood flow from the brachiocephalic artery to the aortic arch is secured. All endovascular procedures can be performed under this situation. Our technique could be effective for preventing intraoperative stroke for endovascular repair with the debranching method for aortic arch pathology.

Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography.

Although spontaneous coronary artery dissection (SCAD) is usually diagnosed by coronary angiography, diagnosis may be missed because of various presentations and imperfections of coronary angiography. We report a case of a 41-year-old female with pregnancy-related SCAD who presented with cardiac arrest. Initial coronary angiography was normal without intimal flap. Unexpectedly, 4 days after admission, SCAD in left main trunk was revealed with recurrent myocardial infarction. Intimal flap was sealed at the time of first angiography and this is an interesting point that made us report this case. SCAD is a rare but not negligible cause of not only acute myocardial infarction but also sudden cardiac arrest even if first coronary angiography is normal. .

Right ventricular thrombus in a patient with nephrotic syndrome.

We treated a 21-year-old man with right ventricular thrombus caused by nephrotic syndrome. The right ventricular thrombus was safely removed and his postoperative course was uneventful. Peri- and postoperative management after surgery for the worsened nephrotic syndrome was relatively unique and difficult, and critical care was essential for saving the patient's life and protecting renal function.

Partial resection of cystic tumor of atrioventricular node.

We treated a 57-year-old female patient with an atrial tumor that was widely attached to the atrial septum. The tumor was diagnosed as a cystic tumor of the atrioventricular node (CTAVN). This type of tumor is rare, and its antemortem diagnosis is difficult because it is usually asymptomatic. This tumor may cause sudden death; thus surgical resection is recommended. We performed partial resection instead of total resection to avoid pacemaker implantation.

Open heart surgery after renal transplantation.

AIM: to evaluate the strategy for open heart surgery after renal transplantation performed in a single institution in Japan. METHODS: we reviewed 6 open heart surgeries after renal transplantation in 5 patients, performed between January 1992 and December 2012. The patients were 3 men and 2 women with a mean age of 60 ± 11 years (range 46-68 years). They had old myocardial infarction and unstable angina, aortic and mitral stenosis, left arterial myxoma, aortic stenosis, and native valve endocarditis followed by prosthetic valve endocarditis. Operative procedures included coronary artery bypass grafting, double-valve replacement, resection of left arterial myxoma, 2 aortic valve replacements, and a double-valve replacement. Renal protection consisted of steroid cover (hydrocortisone 100-500 mg or methylprednisolone 1000 mg) and intravenous immunosuppressant infusion (cyclosporine 30-40 mg day(-1) or tacrolimus 1.0 mg day(-1)). RESULTS: 5 cases were uneventful and good renal graft function was maintained at discharge (serum creatinine 2.1 ± 0.5 mg dL(-1)). There was one operative death after emergency double-valve replacement for methicillin-resistant Staphylococcus aureus-associated prosthetic valve endocarditis. Although the endocarditis improved after valve replacement, the patient died of postoperative pneumonia on postoperative day 45. CONCLUSIONS: careful perioperative management can allow successful open heart surgery after renal transplantation. However, severe complications, especially methicillin-resistant Staphylococcus aureus infection, may cause renal graft loss.

Is physiologic annular dynamics preserved after mitral valve repair with rigid or semirigid ring?

BACKGROUND: Various rings are available to achieve more physiologic mitral valve repair from viewpoints of physiologic mitral annular structure or dynamics. We evaluated preoperative and postoperative mitral annular structures and dynamics. METHODS: Thirty-six patients underwent mitral valve repair for degenerative mitral insufficiency. Carpentier-Edwards Physio II ring (semirigid [Edwards Lifesciences, Irvine, CA]), St. Jude Medical Rigid Saddle Ring (RSR [St. Jude Medical, St. Paul, MN]), and MEMO 3D ring (semirigid [Sorin SpA, Milan, Italy]) were implanted in 13, 12, and 11 patients, respectively. Intraoperative real-time three-dimensional transesophageal echocardiography was performed before and after repair. RESULTS: The postoperative anteroposterior diameter reduction rate from end diastole to end systole was significantly (p<0.0001) larger in MEMO (9.58%±2.91%) than in Physio II (0.98%±1.04%) and RSR (1.94%±1.95%). There were no significant differences in the commissure-to-commissure diameter reduction rates among the groups: 0.81%±1.98% for Physio II, 0.12%±0.53% for RSR, and 0.51%±1.98% for MEMO. The postoperative end-systolic annular height commissure width ratio was significantly (p<0.0001) larger in both Physio II (17.9%±3.0%) and RSR (18.5%±1.6%) than in MEMO (13.6%±3.0%). The postoperative annular height commissure width ratio increase rate from end diastole to end systole was significantly larger in MEMO (5.1%±2.3%) than in Physio II (0.1%±0.6%) and RSR (0.3%±0.5%). CONCLUSIONS: Physio II and RSR could restore the physiologic three-dimensional annular shape, but the annular motion was diminished. Conversely, MEMO could preserve both the anteroposterior movement and folding dynamics, but no three-dimensional restoration of the mitral annulus was obtained.

Subepicardial aneurysm by venting catheter via the right superior pulmonary vein.

Subepicardial aneurysm caused by a left ventricular venting catheter inserted from the right superior pulmonary vein is very rare. Generally, this type of aneurysm is a complication of acute myocardial infarction. We report a 76-year-old woman in whom a left ventricular aneurysm was shown by transthoracic echocardiography 3 years after mitral valve replacement. She underwent left ventricular aneurysmectomy via the 4(th) left intercostal space. The left ventricular aneurysm was separated from the pericardium completely; therefore, this aneurysm was not thought to be pseudoaneurysm. The postoperative course was uneventful and the aneurysm was diagnosed as a subepicardial aneurysm from a histological examination.

Edaravone Suppresses Reperfusion Injury following Leg Ischemia in Rats: A Transmission Electron Microscopic Study.

It is well known that free radicals cause reperfusion injury following leg ischemia. We showed that the free radical scavenger, edaravone (Radicut, Mitsubishi Tanabe Pharma Co., Osaka, Japan), might suppress reperfusion injury in rat. In this study, we used transmission electron microscope (TEM) to investigate how edaravone suppresses reperfusion injury by focusing on glycogen granules in the lower extremity muscles. Male Lewis rats (582 ± 35 g) were intraperitoneally injected with edaravone (3.0 mg/kg, edaravone group, n = 5) or the same dose of saline (control group, n = 5). The rat reperfusion injury models were induced by clamping the bilateral common femoral arteries for 5 hours and then declamping. The muscles were harvested at 5 hours after the start of reperfusion. Under a TEM (JEM-1220, Nippon Denshi Co., Tokyo, Japan), we counted the number of glycogen granules at ×50,000 magnification on each five different fields. The TEM sections from the control group showed a marked loss of glycogen granules and swollen mitochondria. In contrast, the TEM sections from the edaravone group showed numerous glycogen granules and normal mitochondria. The mean density of glycogen granules in the edaravone group was significantly higher than that in the control group (88.5 ± 5.3 vs. 16.4 ± 3.1 particles/µm(2), p < 0.001). Our TEM results confirmed that edaravone suppresses reperfusion injury following leg ischemia by maintaining the glycogen granules in muscles.

Temporary axillo-femoral bypass during open repair for abdominal aortic aneurysm: report of a case.

Open repair is the "gold standard" treatment for abdominal aortic aneurysm (AAA) and although considered safe, this operation is very invasive for high-risk patients with severe aortic valve stenosis (AS) because the left ventricular after-load changes sharply with the clamping and unclamping of the aorta. We prevented the change in left ventricular after-load by establishing a temporary axillo-bilateral femoral arterial shunt, which enabled us to perform open repair of an AAA safely in a patient with severe AS.