[Coronary Artery Fistula with Aortic Valve Stenosis:Report of a Case].

A coronary artery fistula usually originates in the right coronary artery and often opens into the right ventricle. In approximately 50% of cases with a main pulmonary artery opening, aberrant blood vessels originate from both coronary arteries. Only a few cases of both coronary and bronchial artery-pulmonary artery fistulas have been reported. The patient was an 83-year-old man. Echocardiography showed severe aortic stenosis, while coronary angiography revealed aberrant vessels from both coronary arteries to the pulmonary artery. The right heart catheterization revealed a 26% left-to-right shunt ratio and a pulmonary/body blood flow ratio (Qp/Qs) of 1.36. MDCT scan confirmed that the aberrant vascular plexus originating from both coronary arteries was connected to the bronchial artery. We performed surgery on the patient, replacing the aortic valve and resecting the coronary arteriovenous fistulas. On the 11th postoperative day, the shunt had disappeared, as evidenced by a 1.2% left-toright shunt ratio and a Qp/Qs of the right heart catheterization of 1.02. The patient progressed uneventfully and was discharged on the 25th postoperative day.

Early and Late Surgical Outcomes after Geometrical Infarct Exclusion for Post-Infarct Ventricular Septal Perforation.

PURPOSE: Ventricular septal perforation (VSP) is a critical complication of acute myocardial infarction. Various surgical procedures for it have been developed; however, surgical outcomes remain unsatisfactory. In 2010, we introduced geometrical infarct exclusion (GIE) as a modification of the Komeda-David technique. This retrospective study compared the surgical outcomes of our geometric infarct exclusion technique to those of other surgical procedures. METHODS: This study included 38 patients who underwent surgery for VSP. They were divided into patients who underwent GIE (GIE group; n = 17) and those who underwent other procedures (non-GIE group; n = 21). The clinical outcomes of the two groups were compared. RESULTS: Operation, cardiopulmonary bypass, and cardiac arrest times in the GIE group were significantly longer than those in the non-GIE group (p <0.001). A residual shunt was observed in one patient (5.8%) in the GIE group and eight (38.0%) in the non-GIE group (p = 0.026). No patients in the GIE group required a reoperation for the residual shut, while two patients required it in the non-GIE group (p = 0.492). Operative mortality was insignificantly different between the two groups. CONCLUSION: Geometric infarct exclusion has a longer procedural time than does other surgical procedures but can reduce the rates of residual shunts and reoperations.

[Re-operation with Infarct Exclusion Technique due to Residual Shunt after Extended Sandwich Patch Technique for Postinfarction Ventricular Septal Perforation:Report of a Case].

We report a case in which infarct exclusion technique was used to repair residual shunt after extended sandwich patch technique for postinfarction ventricular septal perforation (VSP). A 76-yearold woman was diagnosed with postinfarction VSP and underwent extended sandwich patch technique through right ventriculotomy on the third day after the onset of VSP. No residual shunt was then observed by intraoperative transesophageal echocardiography, but a slight residual shunt was observed on the 7th day after operation. She had no symptom of cardiac failure, and was followed up. However, the residual shunt worsened, and she developed cardiac failure on the 48th day after the initial operation. An additional operation by infarct exclusion technique was performed. No residual shunt was observed after the additional operation. She has been doing well with no signs of cardiac failure.

[Transmitral Septal Myectomy and Mitral Valve Plasty for Hypertrophic Obstructive Cardiomyopathy Combined with Organic Mitral Regurgitation;Report of a Case].

A 60-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) combined with organic mitral regurgitation underwent transmitral septal myectomy and mitral valve plasty. Although a transaortic septal myectomy (Morrow's procedure) is generally accepted as the standard surgical treatment for HOCM, it may be difficult to perform sufficient septal myectomy for mid-ventricular obstructive hypertrophic cardiomyopathy and apical hypertrophic cardiomyopathy (HCM). The transmitral approach with temporary detachment of the anterior mitral leaflet provides a good surgical view in the left ventricle, which allows sufficient septal myectomy from the outflow tract to the apex.

Total arch replacement for the treatment of a giant protruding thrombus in the thoracic aorta derived from an atherosclerotic lesion.

A thoracic aortic thrombus is rare. The causes of this condition and the feasible options for its treatment remain controversial. Preventing embolic complications are the most important for the management of thoracic aortic thrombi. Herein, we report a case of a giant protruding thrombus in the thoracic aorta. We suggest total arch replacement (TAR) using an open stent graft (OSG) as a favorable management technique for thoracic aortic thrombi. We also recommend bilateral axillary artery cannulation to prevent cerebral infarction.

Pseudoaneurysm of the ascending aorta 31 years after mitral valve replacement.

We describe a rare case of an ascending aortic pseudoaneurysm 31 years after mitral valve replacement with a Björk-Shiley mechanical valve. The aneurysm presumably expanded gradually during the years following surgery. As the valve was functioning normally, it was left in situ while the ascending aorta was replaced. This report provides valuable information regarding the long-term nature of this patient's pseudoaneurysm, and the long-term durability of the Björk-Shiley spherical valve in the mitral position.

Mortality and morbidity after total aortic arch replacement.

BACKGROUND: Total aortic arch replacement is associated with considerable mortality and morbidity. Although operative death is the most extreme adverse clinical end point, postoperative morbidity can also be devastating for survivors. METHODS: We examined the short-term and long-term outcomes of 146 patients who underwent total aortic arch replacements between September 2003 and September 2011. RESULTS: The overall in-hospital mortality was 4.8%, and major postoperative morbidity during hospitalization occurred in 29 patients (19.9%). Multivariate analyses demonstrated that risk factors for hospital death were left thoracotomy (odds ratio [OR], 51.92; p=0.01), high preoperative serum creatinine values (OR, 3.88; p=0.02), and intraoperative blood loss (OR, 1.01; p=0.04). Ruptured aorta (OR, 7.13; p=0.02) and previous myocardial infarction (OR, 5.13; p=0.04) were identified as independent risk factors for major postoperative morbidity. The postoperative survival of all patients at 5 years was 76.7%±5%. After hospital discharge, the standardized mortality ratios showed no significant difference between hospital survivors and a comparable Japanese population and were 1.09 (p=0.41) among patients without major morbidity and 1.82 (p=0.12) among those with major morbidity. The development of renal failure requiring hemodialysis increased the risk of long-term death (hazard ratio, 5.59; p=0.03), even among hospital survivors. CONCLUSIONS: Our approach for total arch replacement resulted in low in-hospital mortality and morbidity. Long-term outcomes are stable in hospital survivors, especially in the absence of a postoperative requirement for dialysis.

Arch translocation and the intra-arch elephant-trunk technique with collared graft for extended chronic dissecting aortic aneurysm.

Management of extensive, chronic, dissecting aortic aneurysms after prior repair of the ascending aorta presents a technical challenge for surgeons. A symptomatic 64-year-old patient was admitted for elective surgical repair of an aortic annular dilatation, causing severe aortic regurgitation, and a Crawford type II extended thoracoabdominal aneurysm, 4 years after he underwent primary repair of an acute aortic dissection. The aorta was diffusely dilated, and there were no sites beyond the distal aortic arch where anastomosis could be performed. We successfully performed total aortic replacement with a 2-stage strategy, using an arch translocation technique and an intra-arch elephant-trunk technique.

The effects of mechanical stress on the growth, differentiation, and paracrine factor production of cardiac stem cells.

Stem cell therapies have been clinically employed to repair the injured heart, and cardiac stem cells are thought to be one of the most potent stem cell candidates. The beating heart is characterized by dynamic mechanical stresses, which may have a significant impact on stem cell therapy. The purpose of this study is to investigate how mechanical stress affects the growth and differentiation of cardiac stem cells and their release of paracrine factors. In this study, human cardiac stem cells were seeded in a silicon chamber and mechanical stress was then induced by cyclic stretch stimulation (60 cycles/min with 120% elongation). Cells grown in non-stretched silicon chambers were used as controls. Our result revealed that mechanical stretching significantly reduced the total number of surviving cells, decreased Ki-67-positive cells, and increased TUNEL-positive cells in the stretched group 24 hrs after stretching, as compared to the control group. Interestingly, mechanical stretching significantly increased the release of the inflammatory cytokines IL-6 and IL-1ß as well as the angiogenic growth factors VEGF and bFGF from the cells in 12 hrs. Furthermore, mechanical stretching significantly reduced the percentage of c-kit-positive stem cells, but increased the expressions of cardiac troponin-I and smooth muscle actin in cells 3 days after stretching. Using a traditional stretching model, we demonstrated that mechanical stress suppressed the growth and proliferation of cardiac stem cells, enhanced their release of inflammatory cytokines and angiogenic factors, and improved their myogenic differentiation. The development of this in vitro approach may help elucidate the complex mechanisms of stem cell therapy for heart failure.

Validation of the JapanSCORE versus the logistic EuroSCORE for predicting operative mortality of cardiovascular surgery in Yamaguchi University Hospital.

PURPOSE: Recent studies have shown that the European System for Cardiac Operative Risk Evaluation (Euro-SCORE) is a reliable risk model in cardiac surgery. In Japan, the JapanSCORE has been devised as the Japanese original risk model for cardiovascular surgery. We evaluated the validity of the JapanSCORE, especially in comparison with the logistic EuroSCORE METHODS: We calculated the predicted mortality according to two risk models for 523 consecutive patients who underwent cardiovascular surgery within a 6-year period (July 2003 to June 2009) at Yamaguchi University Hospital. We assessed the scores' validity by calculating the area under the receiver operating characteristics curve (C-index) and by the chi-squared test or Fisher's exact test. RESULTS: The C-indexes were 0.688 with the logistic EuroSCORE and 0.770 with the JapanSCORE (P = 0.053). Although the difference was not significant, the JapanSCORE tended to be more accurate. The C-indexes limited to isolated coronary artery bypass grafting (CABG) were 0.564 with the logistic EuroSCORE and 0.790 with the JapanSCORE (P = 0.001). The Japan-SCORE was significantly more valid than the logistic EuroSCORE for isolated CABG. The actual mortality was 4.0%; the mean predictive mortality was 5.6% with the JapanSCORE and 15.1% with the logistic Euro-SCORE. The mortality predicted by the JapanSCORE was closer to the observed mortality. There was a significant difference between the observed mortality and the logistic EuroSCORE (P < 0.0001). CONCLUSION: The JapanSCORE seems to be a more reliable risk model than the logistic EuroSCORE for patients undergoing cardiac or thoracic aortic surgery at Yamaguchi University Hospital.

[Early results of surgical repair of ventricular septal rupture].

BACKGROUND AND OBJECTIVE: Ventricular septal rupture (VSR) is a lethal complication of acute myocardial infarction, and its operative results are far from good. SUBJECTS: Six patients who underwent operations for VSR in our department between 2001 and 2008. All these patients received coronary angiography, which showed 1-vessel disease in 4 patients, 2-vessel disease in 1, and 3-vessel disease in 1. The sites of myocardial infarction were the anteroseptal region in 3 patients and the inferoseptal region in 3. RESULTS: Infarct exclusion was conducted in the 3 patients with anteroseptal infarction. Of the 3 patients with inferoseptal infarction, 1 underwent infarct exclusion and 2 Daggett operation. The number of in-hospital deaths was 3 (50%). Residual shunts were observed in 3 out of the 4 patients (75%) who had received infarct exclusion. Two of these 3 patients needed reoperation. The 2 patients with inferoseptal infarction who had undergone Daggett operation presented no residual shunts, and could be easily weaned from the cardiopulmonary bypass. CONCLUSIONS: Because the infarct exclusion method frequently shows residual shunts, its technical modifications are required to improve the operative results. The Daggett method can be considered useful in patients with VSR after inferior myocardial infarction.

Influence of carotid artery stenosis on stroke in patients undergoing off-pump coronary artery bypass grafting.

OBJECTIVE: It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified. METHODS: We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. RESULTS: Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor in-hospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. CONCLUSIONS: The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis.

[Strategy for thrombosed type A acute aortic dissection].

The surgical treatment for thrombosed type A aortic dissection is controversial. We treated 15 cases (28.8%) with thrombosed type A acute aortic dissection among 52 cases of all type A acute aortic dissection during past 7 years and 8 months. Nine cases was treated conservatively and 6 cases received emergent operation due to cardiac tamponade, shock, and ulcer-like projection (ULP) in the ascending aorta (> 50 mm). In the group of conservative therapy, 2 cases in which the ascending aorta was enlarged (54, 60 mm), was converted to operation in the acute phase because of further enlargement of ascending aorta and increase of cardiac effusion. The other patients (aortic diameter: 40-46 mm) who received conservative therapy were well controlled by medical therapy in the early and late phase except 1 who died suddenly in the follow-up. There was no mortality and late death in the operated patients. From these results, we conclude that thrombosed type A aortic dissection in which the diameter of ascending aortic aorta is larger than 50 mm, have cardiac tamponade and ULP in the ascending aorta might needs operation.

Angiogenesis induced by the injection of peripheral leukocytes and platelets.

BACKGROUND: Peripheral leukocytes and platelets (LAPs) contain many kinds of cells with the ability to secrete several growth factors and cytokines. We attempted to induce therapeutic angiogenesis by injecting self-LAPs into a rat ischemic hindlimb model. MATERIALS AND METHODS: Supernatants from cultured LAPs were used for the endothelial cell (EC) proliferation assay, and LAPs were used in a cornea model to evaluate angiogenic potency. LAPs were injected directly into the male Dark Agouti rat ischemic hindlimb model, after which a microangiogram was done and the capillary/muscle fiber ratio was examined histologically. ELISA revealed the levels of contributing growth factors and cytokines present in the ischemic muscles. RESULTS: The EC proliferation assay showed that the supernatants of LAPs accelerated proliferation and that the LAPs induced angiogenesis in the cornea model. The microangiograms and histological evaluation revealed that angiogenesis was induced more effectively in the rats injected with LAPs (LAP group) than in the those injected with phosphate-buffered saline (PBS group). The levels of basic fibroblast growth factor (bFGF) in the ischemia, PBS, and LAP groups were significantly increased compared to those in the sham group. The level of interleukin-1beta (IL-1beta) in the LAP group was significantly more elevated than in the other groups. CONCLUSIONS: The injection of self-LAPs induced angiogenesis in a rat ischemic hindlimb model. Ischemia caused an elevation in the level of bFGF and also in IL-1beta derived from LAPs, which contributed to angiogenesis. This is a novel, yet simple and safe method of inducing therapeutic angiogenesis.