Left atrial myxoma mimicking papillary fibroelastoma.

A 67-year-old woman was referred to our hospital with a diagnosis of deep vein thrombosis due to surgery for left patellar fracture. Deep vein thrombosis resolved with thrombolytic therapy. Transthoracic echocardiogram revealed a mobile left atrial tumor. Transesophageal echocardiography showed a fragile tumor with multiple fronds, implying a papillary fibroelastoma. Because this patient had a history of cerebral embolism, urgent surgery was scheduled. The excised tumor showed a sea anemone-like appearance in saline, which was similar to that of a papillary fibroelastoma. However, histological examination revealed the features of a myxoma and not papillary fibroelastoma. Herein, we illustrate a very rare case of left atrial myxoma with papillary fibroelastoma-like features in terms of both echocardiographic and gross findings.

Preoperative computed tomographic diagnosis of an aortocaval fistula associated with aneurysm of the abdominal aorta.

Aortocaval fistula is a rare but life-threatening complication of ruptured abdominal aortic aneurysm. We present a case of an aortocaval fistula with acute right heart failure. The condition was accurately diagnosed before operation by physical examination, echo, and especially by computed tomography (CT), thereby enabling proper planning of the operative strategy. At surgery, not only the infrarenal aorta and common iliac arteries on both sides but the inferior vena cava and iliac veins on both sides were also controlled to avoid massive venous bleeding through the fistula. Aortocaval fistula repair was easy, and conventional bifurcated Dacron graft replacement for abdominal aortic aneurysm was successfully performed. Innovative CT images give us prompt preoperative diagnoses and elaborate surgical strategies.

Gas-containing pericardial abscess in a type 2 diabetic patient.

A 63-year-old male with type 2 diabetes mellitus was admitted to our hospital with fever and chest pain. An echocardiogram, chest CT and MRI showed the gas-containing pericardial abscess located posteriol to the right atrium. He was initially treated by thoracoscopic pericardial fenestration to set a drainage tube in the pericardial abscess. However, the surgical treatment was discontinued because of a large amount of bleeding from the abscess wall. The patient was then treated by continued administration of antibiotics and gamma-globulin. The inflammatory reactions improved and shrinkage of the abscess was confirmed.

Graft replacement for massive mobile embolic source in brachiocephalic artery.

A 76-year-old woman presented with multiple brain infarctions in the right middle cerebral artery and vertebral artery area. Carotid sonography revealed a large mobile pedunculated mass in the brachiocephalic artery, which showed rapid growth despite treatment with heparin and aspirin. Graft replacement of the brachiocephalic artery was performed under selective cerebral perfusion with deep hypothermia. Histology of the resected specimen revealed aortic atherosclerotic plaque.

Transcranial Doppler study to assess intracranial arterial communication before aortic arch operation.

BACKGROUND: The assessment of intracranial arterial communication is important to prevent a stroke from occurring during an aortic arch operation. Bilateral axillary artery perfusion was used with the left common carotid artery perfusion for selective cerebral perfusion. A preoperative left carotid artery compression test with measurement of the left middle cerebral artery (LMCA) flow was performed to determine how safe it was to interrupt the perfusion to the left common carotid artery. METHODS: Eighteen patients who were scheduled for an aortic arch operation underwent the test. Before surgery, the LMCA flow was detected using transcranial Doppler ultrasonography. During manual compression of the left carotid artery, the flow velocity of the LMCA was measured and expressed as a percent in comparison to the precompression value. RESULTS: During carotid artery compression, flow velocity of the LMCA was reduced to 56% +/- 36% (median, 63%; range, 0% to 100%) of the precompression value. The communication to the LMCA assessed with magnetic resonance angiography showed a weak relationship to the functional flow reserve of the LMCA based on a transcranial Doppler study. The results indicated that morphologic observation with magnetic resonance angiography did not reflect the dynamic nature of the intracranial collaterals. CONCLUSIONS: A preoperative left carotid artery compression test with a measurement of the flow of the LMCA is useful to assess the feasibility of interrupting perfusion to the left carotid artery during aortic arch surgery with bilateral axillary artery perfusion.

IgG4-positive plasma cells in inflammatory abdominal aortic aneurysm: the possibility of an aortic manifestation of IgG4-related sclerosing disease.

Inflammatory abdominal aortic aneurysm (IAA) is associated with autoimmune disease. However, the precise mechanism of IAA remains unclear. There is increasing evidence that IgG4 is involved in the autoimmune mechanism of various idiopathic sclerosing lesions, including sclerosing pancreatitis and retroperitoneal fibrosis. The present study investigated the hypothesis that the IgG4-related autoimmune reaction is involved in the formation of IAA. The study group consisted of 11 cases of IAA (69.2 +/- 8.59y) and 12 age-matched cases of atherosclerotic abdominal aortic aneurysm (AAA, 69.6 +/- 5.94y), which were used in the previous report. A clinicopathologic examination of these lesions was performed, including histology and immunohistochemistry, in relation to the involvement of IgG4-positive plasma cells in the formation of IAA. No difference in the incidence of risk factors for atherosclerosis was observed between the patients with IAA and AAA. Autoimmune diseases were diagnosed in 2 patients with IAA, including rheumatoid arthritis and polyarteritis nodosa. A patient with IAA had pulmonary fibrosis. In contrast, autoimmune diseases were absent in patients with AAA. However, there was no significant difference in the incidence of autoimmune diseases between the patients with IAA and AAA. Lymphocyte and plasma cell infiltration and fibrosis were significantly more intense and extensive in IAA than in AAA. In addition, lymph follicle formation and vasculitis of small veins and arteries were frequently found in the affected lesions of IAA. Immunohistochemically, IAA showed a significant increase in the number of infiltrating IgG4-positive plasma cells and the incidence of a disrupted follicular dendritic cell network in lymph follicles, in comparison with AAA. These findings suggest that IAA may be an aortic lesion reflecting the presence of IgG4-related sclerosing disease, and not a simple inflammatory aneurysm of the aorta.

Aortic valve replacement with 17-mm St. Jude Medical prostheses for a small aortic root in elderly patients.

BACKGROUND: There are few reports about the optimal prosthesis for elderly patients who have small aortic roots with an aortic annular size of less than 19 mm. METHODS: From October 2004 to October 2006, 11 women aged 70 years or older (mean age, 74.9 +/- 3.5 years) underwent aortic valve replacement with a 17-mm Regent prosthesis (St. Jude Medical, St. Paul, MN), with the size determined using the manufacturer's sizer. Clinical status and the results of preoperative and postoperative echocardiography were evaluated. RESULTS: The patients had a mean body surface area of 1.33 +/- 0.13 m2. Preoperative average New York Heart Association (NYHA) functional class was 2.5 +/- 0.7. Preoperative echocardiography showed a mean indexed effective orifice area of 0.33 +/- 0.14 cm2/m2 and a left ventricular mass index of 175 +/- 63 g/m2. Seven patients underwent associated procedures. Postoperative ventilation time was 14 +/- 5.6 hours, and the intensive care unit stay was 1.0 +/- 0.4 days. No patients died perioperatively. The NYHA functional class improved to class I in 9 patients. No obstruction of valve opening was observed. A significant increase in the mean indexed effective orifice area (0.87 +/- 0.10 cm2/m2) and regression of left ventricular mass index were found (114 +/- 46 cm2/m2) on postoperative echocardiography. CONCLUSIONS: Aortic valve replacement in elderly patients with small aortic roots (less than 19 mm) using a 17-mm Regent prosthesis showed satisfactory clinical and hemodynamic results.

[Inflow cannula direct insertion into the true lumen of the ascending aorta for an acute aortic dissection patient with intraoperative malperfusion after aortic clamping].

A 47-year old woman, who was diagnosed as Stanford type A acute aortic dissection, underwent an emergent operation. Because of obesity and bleeding, it was impossible to find the right axillary artery. Only we could have for inflow line was the femoral line. After starting cardiopulmonary bypass (CPB) and crossclamping the ascending aorta, mean blood pressure of the right radial artery dropped to 15 mmHg, suggesting the occurrence of malperfusion. The ascending aorta was immediately transected, and the CPB was ceased. Inflow cannula was directly inserted into the true rumen of the ascending aorta, and resumed the CPB. The mean blood pressure rose up to 80 mmHg. Such procedure took about 10 minutes. Abnormal neurological findings were not apparent except for the transient postoperative delirium. The patient was discharged on the 48th day after operation. It is suggested that this method was useful and safe to have the new inflow line when emergently necessary.

Replacement of an aortic Starr-Edwards ball valve prosthesis 28 years after implantation.

A 53-year-old woman who had undergone aortic valve replacement with a Starr-Edwards (S-E) valve (Model 1260) and open mitral commissurotomy 28 years previously was hospitalized with cardiac failure. Echocardiography showed mitral stenosis, mitral regurgitation, and a normally functioning S-E prosthesis. At reoperation, the mitral and aortic valves were replaced with St Jude bileaflet mechanical prostheses. Examination of the explanted S-E prosthesis revealed no structural abnormality other than lipid infiltration of the silastic ball.

Usefulness of a multidetector-row computed tomography scanner for detecting pannus formation.

BACKGROUND: Prosthetic valve dysfunction (PVD) as a result of pannus or thrombus formation is an infrequent but serious complication. Currently available diagnostic tools, however, are insufficient to detect a minute pannus and thrombi. The use of a more advanced diagnostic image, multidetector-row computed tomography scanner, may enable us to determine the anatomic and functional causes of PVD. METHODS: Patients who underwent aortic valve replacement with a St. Jude Medical valve were examined by transthoracic echocardiography and cineradiography to diagnose PVD. Sixteen patients with PVD (PVD group) and 12 patients with normal prosthetic valve function (control group) were studied using the multidetector-row computed tomography scanner. The multidetector-row computed tomography findings in 2 patients with PVD were validated by the observations during reoperation. RESULTS: In 13 of 16 patients (81%) in the PVD group and 3 of 12 patients (25%) in the control group, multidetector-row computed tomography demonstrated that an abnormal small tissue, regarded as pannus, was found to extend from the left ventricular septum into the pivot guard. These findings were confirmed by the observations during reoperation in 2 patients in the PVD group. CONCLUSIONS: Multidetector-row computed tomography can be a useful diagnostic technique for anatomic and functional evaluation of PVD as a result of pannus formation.

Non-occlusive condition with the Better-Header roller pump: impacts of flow dynamics and hemolysis.

PURPOSE: Impacts on hemolysis and backflow using a non-occlusive setting with the Better-Header (BH) roller pump were investigated. METHODS AND RESULTS: Pump flow of a non-occlusion setting was measured with a pump speed of 3 L/min and 5 L/min against various after-loads. With the non-occlusive setting (BH-NO350), backflow was less than 10% if the pump pressure head was <300 mmHg. When the outlet line is occluded, 80% of the set flow was shunted through the pressure relief valve and outlet pressure did not develop hazardous overpressure. During surgery with the BH-NO350, flow loss was <5% while the pump pressure was maintained at approximately 200 mmHg. An in vitro hemolysis test was conducted at 5 L/min against 350 mmHg, using the standard occlusion (BH-SO), the non-occlusion (BH-NO350), and the centrifugal pump (CP). The CP demonstrated less hemolysis than the other two groups; the BH-SO and the BH-NO350 had similar hemolytic characteristics. During cardiopulmonary bypass, no significant differences in hemolysis were seen among the BH-SO, the BH-NO350, and the CP. CONCLUSION: Possible flow loss of the non-occlusion setting with the BH should be almost negligible in most clinical situations. The BH-NO350 demonstrated hemolytic characteristics similar to those of the BH-SO, but not as good as those of the CP.

Obstruction of St Jude Medical valves in the aortic position: histology and immunohistochemistry of pannus.

OBJECTIVE: This study aims to reveal the morphological, histological, and immunohistochemical mechanism of pannus formation using resected pannus tissue from patients with prosthetic valve dysfunction. METHOD: Eleven patients with prosthetic valve (St Jude Medical valve) dysfunction in the aortic position who underwent reoperation were studied. We used specimens of resected pannus for histological staining (hematoxylin and eosin, Grocott's, azan, elastica van Gieson) and immunohistochemical staining (transforming growth factor-beta, transforming growth factor-beta receptor 1, alpha-smooth muscle actin, desmin, epithelial membrane antigen, CD34, factor VIII, CD68KP1, matrix metalloproteinase-1, matrix metalloproteinase-3, and matrix metalloproteinase-9). RESULTS: Pannus without thrombus was observed at the periannulus of the left ventricular septal side; it extended into the pivot guard, interfering with the movement of the straight edge of the leaflet. The histological staining demonstrated that the specimens were mainly constituted with collagen and elastic fibrous tissue accompanied by endothelial cells, chronic inflammatory cells infiltration, and myofibroblasts. The immunohistochemical findings showed significant expression of transforming growth factor-beta, transforming growth factor-beta receptor 1, CD34, and factor VIII in the endothelial cells of the lumen layer; strong transforming growth factor-beta receptor 1, alpha-smooth muscle actin, desmin, and epithelial membrane antigen in the myofibroblasts of the media layer; and transforming growth factor-beta, transforming growth factor-beta receptor 1, and CD68KP1 in macrophages of the stump lesion. CONCLUSIONS: Pannus appeared to originate in the neointima in the periannulus of the left ventricular septum. The structure of the pannus consisted of myofibroblasts and an extracellular matrix such as collagen fiber. The pannus formation after prosthetic valve replacement may be associated with a process of periannular tissue healing via the expression of transforming growth factor-beta.

Anomalous subaortic left brachiocephalic vein associated with tricuspid atresia: a successful bidirectional cavopulmonary connection.

Anomalous subaortic left brachiocephalic vein is an uncommon systemic venous anomaly. Here we report a case of this anomaly in a 3-month-old male infant with tricuspid atresia. The patient successfully underwent bidirectional cavopulmonary connection without cardiopulmonary bypass, although extended dissection of the bilateral brachiocephalic veins was required. The association of this venous anomaly with tricuspid atresia is extremely rare, and the presented patient is the second successful surgical case in the literature.

Anomalous origin of the left coronary artery from the pulmonary artery: successful direct reimplantation in a 50-year-old man.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital coronary artery anomaly that is often referred to as Bland White Garland syndrome. Most patients with this anomaly require surgical intervention early in life, and it is extremely rare that patients reach middle age without any symptoms. We present a 50-year-old man with this anomaly, who underwent direct reimplantation of the left main coronary trunk to the ascending aorta. His postoperative course was uneventful, and three and a half years after the operation, he is well and does not require medication. Several surgical procedures can be used to treat this anomaly, but we prefer to use direct reimplantation, whenever technically possible. To our knowledge, this patient is the oldest patient to have undergone a direct reimplantation without any angioplasty.

Left atrial thrombus without mitral valve disease in a patient with nephrotic syndrome: report of a case.

Left atrial (LA) thrombi are rarely seen in patients without mitral valve disease. We report the case of a 71-year-old man found to have a large LA thrombus without mitral valve disease. The patient also suffered from atrial fibrillation and nephrotic syndrome (NS), and had a history of transient ischemic attack. Transesophageal echocardiography showed an LA thrombus attached to the LA wall, and a normal mitral valve. Blood chemistry revealed a total serum protein of 4.6 g/dl, with 2.0 g/dl of albumin and a total cholesterol level of 453 mg/dl. The plasma fibrinogen level was 366 mg/dl and the antithrombin III was 103%. An emergency operation was performed to remove the LA thrombus and a normal mitral valve was confirmed. We believe that several factors, including changes in coagulability related to the NS, steroid therapy, and diuretics, in addition to the dilated LA with atrial fibrillation, may have caused the LA thrombus formation in this patient.

Does off-pump coronary artery bypass grafting really preserve renal function?

It is well known that the use of cardiopulmonary bypass (CPB) influences renal function and occasionally results in renal failure following cardiac surgery. Coronary artery bypass grafting (CABG) without CPB may avoid this and preserve the perioperative renal function. The present study enrolled 52 patients undergoing CABG without CPB (OPCAB group) and matched them for renal function and prognostic variables with 53 patients undergoing conventional CABG (CABG group). Perioperative renal function and early clinical results were assessed. The OPCAB group had significantly less increase in creatinine levels (0.16 +/- 0.05 vs 0.45 +/- 0.06 mg/dl; p = 0.01) and greater creatinine clearance (81.6 +/- 7.3 vs 56.3 +/- 4.8ml/min; p = 0.01) postoperatively. Postoperative recovery of free water clearance was more prompt in the OPCAB group. The duration of intubation and intensive care unit stay was significantly shorter, and the creatine kinase-MB release and blood transfusion requirements were significantly less in the OPCAB group. The OPCAB technique preserved glomerular filtration rate and prevented the increase in creatinine levels. The results suggest that the technique enables earlier patient recovery and gives superior renal protection compared with conventional CABG.

Spontaneous coronary artery dissection causing myocardial infarction and left ventricular aneurysm.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction (MI). A 66-year-old Japanese man, who had had an anterior wall MI caused by SCAD of the left anterior descending coronary artery, developed left ventricular aneurysm 5 years later, with depressed left ventricular function and thrombus observed on echocardiography. Left endoventricular circular patch plasty according to Dor's technique was performed without coronary artery bypass grafting, because of the absense of significant coronary artery stenosis on the preoperative coronary angiogram. The clinical course of SCAD in the late phase is generally favorable, but because the prognosis of SCAD is uncertain, patients with SCAD should be carefully followed.

Treatment of acute massive/submassive pulmonary embolism.

Thirty-five consecutive patients with massive and submassive pulmonary embolism (PE) were reviewed. In 75% of these cases, PE could be suspected on the basis of electrocardiogram alone. Echocardiography was quite useful for diagnosing PE and assessing right ventricle after-load at the bedside. Spiral computer tomography was effective for obtaining a definitive diagnosis even in a relatively hemodynamically unstable patient. Thrombolysis therapy was given to 30 cases and was apparently effective in 17 cases (17/30, 56.7%). Percutaneous cardiopulmonary support (PCPS) was needed for 7 severe cases. Seven patients, including 5 of the PCPS recipients, underwent surgical embolectomy. Overall mortality was 28.6% (10/35), and surgical mortality was 28.6% (2/7). The significant predictors for mortality were systolic blood pressure <100 mmHg, dopamine >5 microg x kg(-1) min(-1), pH <7.4, PaCO2 >40 torr, base excesss <-5 mmol/L, urine output <0.8ml x kg(-1) x h(-1), intubation, cardiopulmonary resuscitation, duration from attack to emergency room >5h, shock duration >4h, aspartate aminotransferase >100U/L, alanine aminotransferase >100U/L and lactate dehydrogenase >600U/L. Predictors of surgical intervention were dopamine >5 microg x kg(-1) min(-1), shock duration >4h and PCPS. Early initiation of thombolysis therapy is recommended, except in case where it is absolutely contraindicated. Because it is difficult in the early phase of PE to make a decision to perform surgery, aggressive application of PCPS is recommended for the cardiogenic shock associated with massive PE.

Mitral valve repair in a patient with acromegaly: case report.

A 61-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet. At the age of 51 years, the patient was diagnosed with hypertension and a cardiac murmur. She had the characteristic acromegalic appearance, but without visual disturbance. Blood chemistry revealed an elevated plasma concentration of growth hormone and glucose intolerance. Echocardiography showed remarkable dilation of the left ventricle and prolapse of the anterolateral commissure with severe MR. Magnetic resonance imaging of the brain revealed a pituitary microadenoma. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. The patient recovered uneventfully.

Thrombolytic therapy with tissue plasminogen activator for the treatment of nonstructural malfunction of bileaflet cardiac valve prostheses.

This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis.