[Selective Branch Embolization and Thoracic Endovascular Aortic Repair for Asymptomatic Bronchial Artery Aneurysm:Report of a Case].

Bronchial artery aneurysm (BAA) is a rare disease, for which early treatment is recommended due to the risk of rupture often resulting in severe consequences. We report a case of successful treatment of an asymptomatic BAA by selective branch embolization combined with thoracic endovascular aortic repair (TEVAR). A 68-year-old man was accidentally found to have a bronchial artery aneurysm by computed tomography. The distance from the origin of the bronchial artery to the aneurysm was only 6 mm, at which branches were found. The BAA was completely excluded by selective branch coil embolization and deployment of a thoracic stent graft to cover the orifice of the BAA. Angiography confirmed that there was no endoleak. Selective branch embolization of BAA combined with TEVAR is effective to completely occlude the blood stream to BAA.

Non-pledget commissural suture technique to avoid atrioventricular block.

Here, we report our unique "non-pledget commissural suture technique" to avoid complete atrioventricular block during surgical aortic valve replacement, whereby all commissural stiches are made in a figure-of-eight fashion without a pledget. Then, standard stiches in a non-everting fashion are made using pledget sutures and a prosthetic valve is implanted at the supra-annular position. Among 152 evaluated patients, only five patients experienced complications, including three left bundle branch blocks, one postoperative pacemaker implantation, and one moderate paravalvular leak. Based on the high success rate, our technique may be a reasonable alternative for surgical aortic valve replacement.

A rare form of cardiac myxoma: interatrial septum tumor.

A myxoma is one of the most common tumors in cardiac surgery, with most of them originating from the left or right atrial walls and causing embolic complications. An 84-year-old woman was referred to our institution after echocardiography showed an interatrial septum tumor that was presumed to be a thrombus; however, postoperative pathological examination revealed it to be a cardiac myxoma. This atypical myxoma was covered with a solid capsule containing connective tissue and substantial calcifications, which had made it difficult to establish a diagnosis of myxoma.

Prosthetic Valve Removal Technique Using Ultrasonic Scalpel.

Prosthetic valve removal for reoperative valve replacement is time consuming and has a risk of damage to the heart because of severe adhesions. Prosthetic valves can be removed quickly, easily, and safely by using an ultrasonic scalpel (Harmonic Scalpel, Ethicon Endo-Surgery, Cincinnati, OH). The space between the prosthesis and the native annulus was carefully dissected using Harmonic Synergy blades connected to an Ethicon Gen11 Generator at energy level 5. The average time for prosthetic valve removal using an ultrasonic scalpel was 6 minutes 11 seconds. No patient required new permanent pacemaker implantation.

Bileaflet mechanical valve replacement: an assessment of outcomes with 30 years of follow-up.

OBJECTIVES: Heart valve replacement with a bileaflet mechanical valve is a well-established procedure. However, the long-term results of valve replacement using the bileaflet mechanical valve remain unclear, especially for follow-up periods over 30 years. Additionally, it is important to identify predictors of long-term mortality and valve-related events. METHODS: We performed a retrospective cohort analysis of 2727 patients (mean ± standard deviation age, 52.8 ± 1.6 years) who underwent valve replacement with a St. Jude Medical valve at our institute from 1978 to 2012. Data were collected using a questionnaire and chart review or physician contact. The cohort included 950 aortic valve replacements (AVRs), 1255 mitral valve replacements (MVRs) and 522 double valve replacements (DVRs). Follow-up was 91% complete, and the analysis included a total of 39 187 patient-years. RESULTS: Operative mortality rates were 2.3% for AVR, 2.2% for MVR and 3.6% for DVR. The 30-year survival rate (actuarial method) was 38.0% (AVR, 44.5%; MVR, 34.9%; and DVR, 37.5%). The 30-year rates of freedom from valve-related mortality, thromboembolic events and bleeding events were 86.3% (AVR, 88.6%; MVR, 85.4%; and DVR, 84.3%), 83.5% (AVR, 89.8%; MVR, 80.0%; and DVR, 81.4%) and 91.5% (AVR, 94.4%; MVR, 90.1%; and DVR, 90.2%), respectively. The incidence rates of valve-related morbidity, thromboembolic events and bleeding events were significantly higher among patients with MVR and DVR than among those with AVR. Significant risk factors for late death and other late events included male sex, age >65 years and atrial fibrillation. CONCLUSIONS: Low late mortality and a low incidence of valve-related events can be achieved for at least 30 years using mechanical bileaflet valve replacement. Persistent atrial fibrillation is a significant risk factor for morbidity and mortality.

Left atrial dissection related to retrograde cardioplegia cannula insertion.

Left atrial dissection (LAD) is a rare complication and is defined as a gap from the mitral or tricuspid annular area to the interatrial septum or left atrial wall. Because of its low incidence, this entity is not fully understood. LAD is related to mitral valve surgery as well as coronary artery disease, arrhythmia, trauma, and tumors, and occurs spontaneously. Transesophageal echocardiography is the most useful diagnostic modality for LAD, but multimodality investigation supports accurate diagnosis. We experienced a case of LAD related to retrograde cardioplegia cannula insertion which was treated successfully with internal drainage.

Left atrial dissection.

Left atrial (LA) dissection is a rare complication and is defined as a gap from the mitral or tricuspid annular area to the interatrial septum or left atrial wall. Because of its low incidence, this entity is not fully understood. LA dissection is related to mitral valve surgery as well as coronary artery disease, arrhythmia, trauma, tumor, and spontaneous occurrence. Transesophageal echocardiography is the most useful diagnostic modality for LA dissection, but multimodality investigation supports accurate diagnosis. There are two treatment options for LA dissection: surgical repair and close observation. Surgical repair involves entry closure and internal drainage. The indication for surgery should be based on the clinical presentation.

[Warfarin effects diminishment by the Clostridium butyricum preparation after cardiac surgery; report of a case].

A 55-year-old gentleman diagnosed with severe aortic insufficiency and annuloaortic ectasia underwent modified Bentall procedure using mechanical valve. Anticoagulation therapy with warfarin was introduced after surgery, but sufficient anticoagulation effect was not achieved with a large amount of dosage. After discontinuing the use of the Clostridium butyricum preparation on postoperative day 29, sufficient anticoagulationt effect was obtained within several days. Clostridium butyricum might change the vitamin K production in the intestinal bacterial flora and attenuated the anticoagulation effect of warfarin.

Transtricuspid approach in redo surgery for post-infarction ventricular septal rupture.

A 59-year-old man, who had been treated using the infarction exclusion technique for inferior post-infarction ventricular septal rupture (VSR) 4 months previously, was readmitted because of deterioration of mitral valve regurgitation, residual shunt, and progression of pulmonary hypertension. We performed mitral valve replacement via the transseptal approach, patch closure of the defect via the transtricuspid approach, and tricuspid valve annuloplasty. The post-operative course was uneventful. The transtricuspid approach is useful in redo surgery for post-infarction VSR.

Acute aortic dissection associated with undetected congenital bicuspid aortic valve and infective endocarditis diagnosed intraoperatively.

The congenital bicuspid aortic valve (BAV) is recognized as a cause of acute aortic dissection (AAD) and also as a risk factor for infective endocarditis (IE) especially ring abscess. We experienced a case of all these combined and operated emergently. A 59-year-old man was transferred to us, and emergent operation was indicated for AAD and aortic stenosis (AS) due to BAV. However, he was strongly suspected of also having IE during the operation and the procedure was changed to a modified Bentall's method. The diagnosis was confirmed by pathological examination postoperatively. He recovered well after postoperative antimicrobial therapy without recurrent infection. It is important to remember that BAV is a risk factor for not only AAD but also IE, which sometimes occurs simultaneously and requires an emergent operation due to high mortality.

Successful extracardiac total cavo pulmonary connection (TCPC) after external tracheobronchial stenting for tracheobronchomalacia.

OBJECTIVES: A girl who was diagnosed with cyanotic congenital heart disease in a newborn, showed anoxic spell attacks which we thought were correlated with the congenital heart disease. Although she underwent the palliative operation at 8 months old and her SpO2 was increased, she experienced severe and life-threatening respiratory dysfunction many times after that. After careful examinations, the respiratory complaint was proved to be not only due to cyanotic congenital heart disease but also tracheobronchomalacia. METHOD: She had undergone the external stenting to the trachea and right bronchus at 1 year old. After that, she was examined by cardiac catheterization and the Fontan-type operation was successful using a tissue-engineered graft at 2 years old. RESULTS: Her post-operative course was uneventful and she was discharged. CONCLUSION: It is very important to remember the possible existence of tracheobronchomalacia and prevent a life-threatening attack when congenital cardiac patients experience a prolonged respiratory failure or abnormal respiration.

[Mitral valve plasty and coronary artery bypass grafting under beating heart cardiopulmonary bypass for severe left ventricular dysfunction; report of a case].

A 54-year-old man with ischemic mitral regurgitation and severe heart failure due to broad myocardial infarction successfully underwent mitral valve plasty and coronary artery bypass grafting under beating heart. He had an old anterior myocardial infarction and was admitted to our hospital with acute inferior myocardial infarction. Two weeks later, the cathetelization revealed moderate mitral regurgitation and triple vessel coronary artery disease. We selected antegrade continuous blood perfusion for myocardial protection on operation. He recovered uneventfully and discharged on postoperative day 31. We could perform this procedure safety and satisfactorily, we could this procedure for heart valve operation with other complications.

Transapical aortic cannulation using a deep hypothermic procedure through a left thoracotomy for acute traumatic aortic rupture.

We describe a transapical aortic cannulation procedure through a left thoracotomy for a case of acute traumatic aortic rupture. A 26-year-old man was involved in a motor vehicle accident and admitted in a state of hypovolemic shock. Chest computed tomography findings revealed a rupture of the proximal portion of the descending aorta and a massive hematoma around the aorta extending into the thoracic cavity. Under hypothermic circulatory arrest, he underwent an emergency graft replacement through a left thoracotomy. We used transapical aortic cannulation together with femoral cannulation, in order to avoid malperfusion of the brain and upper body that can occur as a result of retrograde perfusion. The postoperative outcome was favorable. Transapical cannulation is a useful alternative for hypothermic aortic operations through a left thoracotomy.