[Coronary Embolism Probably Caused by Surgical Glue after Operation for Acute Aortic Dissection;Report of a Case].

A 70-year-old female underwent an emergency replacement of the ascending aorta for acute aortic dissection. We used surgical adhesive BioGlue and teflon felt strips to reinforce the dissected aortic wall. On the 5th post operative day, electrocardiogram showed ischemic inverted T wave and the serum creatine phosphokinase level elevated without any symptoms such as chest pain or low blood pressure. By coronary angiography, severe stenosis was detected of the left descending coronary artery, and percutaneous coronary intervention was performed. Intravascular ultrasound images revealed that no atherosclerotic components were present in the embolic materials. As a result of in vitro examination, that material was probably a fragment of the BioGlue. The patient was discharged on foot 23 days after surgery.

[Infectious endocarditis complicated with preoperative infectious intracranial aneurysm;report of a case].

A 44-year-old man was admitted with the diagnosis of active infective endocarditis( IE) due to Streptococcus mitis, complicated with infectious intracranial aneurysm. Preoperative echocardiography showed mobile vegetation on the mitral leaflet, size of which was 20 mm. The magnetic resonance imaging( MRI) demonstrated that the size of aneurysm was increasing, and infectious intracranial aneurysm was treated surgically. Twenty one days after the operation, the mitral valve plasty was performed. He was discharged on foot without any neurological findings. The duration between the brain surgery and the cardiac surgery was thought to be important to prevent the new neurological complication.

[Restenosis following descending aortic replacement for coarctation of the aorta; report of a case].

We report a case of a 44-year-old man with restenosis of coarctation of aorta (CoA). He had a history of descending aortic replacement for CoA using a graft 14 mm in diameter at 29 years ago. He had reoperation because of pressure gradient of 61 mmHg across the graft and intermittent claudication. Reoperation was done under unilateral lung ventilation with lung collapsed, through 3th and 5th interspace thoracotomy. Left lung adhesion was carefully released with an ultrasonically vibrating scalpel. After full heparinization, femoro-femoral bypass was started and descending aorta was clamped. The old graft was excised, and descending aortic replacement was done with a new graft of 26 mm in a diameter. His postoperative course was uneventful. The intermittent claudication disappeared.

[Graft replacement under percutaneous cardiopulmonary system for traumatic aortic rupture with multiple injuries].

We report a case of traumatic aortic rupture with multiple injuries. A 20-year-old man was transferred to our hospital. He was suffering from traumatic thoracic aortic rupture with multiple injuries (femoral fracture, pelvis fracture and so 4th) due to a traffic accident. Enhanced computed tomography revealed leakage from the aortic isthmus and hematoma in the surrounding area. Emergency operation was performed. The left 4th intercostal thoracotomy was performed and a lacerated foramen was observed across the lesser curvature of the aortic isthmus. The affected site was replaced by a prosthetic graft under percutaneous cardiopulmonary system. He was treated with open fixation of the right femur 11 days after the 1st operation. The postoperative recovery was generally uneventful and he was discharged on the 51st hospital day.

[Successful excision of a left ventricular fibroma in an adult patient; report of a case].

A 55-year-old man was referred with a diagnosis of a left ventricular thrombus. Echocardiography revealed that he had a thrombus in the free wall of the left ventricle. Under cardiopulmonary bypass, we removed the intramural tumor. After the removal, the defect was repaired by Dor operation. Pathological examination revealed the tumor was a cardiac fibroma. He is doing well without any troubles 3 years after the operation.

Reduction of mitral valve leaflet tethering by procedures targeting the subvalvular apparatus in addition to mitral annuloplasty.

BACKGROUND: Ischemic mitral regurgitation (IMR) with ischemic cardiomyopathy (ICM) was treated with surgical procedures, and mitral leaflet tethering was assessed. Twenty-two patients with both ICM (left ventricular ejection fraction <0.35) and IMR (>2) underwent coronary artery bypass grafting (CABG), mitral annuloplasty (MAP) with or without surgical ventricular restoration (SVR) and procedures targeting the subvalvular apparatus. METHODS AND RESULTS: Fourteen patients (group 1) underwent CABG and MAP, and the remaining 8 (group 2) underwent CABG, MAP, SVR, papillary muscle approximation (PMA), and papillary muscle suspension (PMS). PMA joined the entire papillary muscles with 3 mattress sutures. For PMS, 2 ePTFE sutures were placed between papillary muscle tips and fibrous annuli. Anterior and posterior mitral leaflet tethering angles (ALA and PLA) relative to the line connecting annuli, posterior and apical displacement of coaptation, and IMR grade were measured on echocardiography. Although preoperative ALA and PLA in group 2 were significantly larger than in group 1, there was no significant difference between groups at 1 month after surgery. At 1 year after surgery, however, the situation reversed: ALA and PLA in group 1 were significantly larger than in group 2. CONCLUSIONS: In addition to MAP, procedures targeting the subvalvular apparatus including PMA and PMS achieved persistent reduction of mitral valve leaflet tethering, which might lead to the improvement of long-term outcome.

Secondary aortoenteric fistula: a case report of acute aortic occlusion following cellulitis.

A secondary aortoenteric fistula is a relatively rare complication of abdominal aortic reconstruction. The clinical manifestation of aortoenteric fistula is usually upper gastrointestinal bleeding. We report a patient who developed acute aortic occlusion following chronic cellulitis, which is an uncommon finding. A 50-year-old man with a history of aortobifemoral bypass grafting was admitted for tiredness, fever and swelling of his right leg. On the 40th day of admission, he developed acute aortic occlusion. Computed tomography revealed right distal aortic graft occlusion and the presence of gas surrounding the graft. Gastroduodenoscopy showed an underlying Dacron graft consistent with an aortoenteric fistula in the third part of the duodenum. We excised the infected graft and reconstructed the abdominal aorta with a new prosthetic graft in situ, which was wrapped with the vascularized pedicle of the omentum. The duodenal defect was repaired with segmental duodenal resection and end-to-end anastomosis. The patient recovered well after surgical management and has remained in good condition for 2 years without developing any signs of recurrence of infection.

Late-stage non-anastomotic rupture of axillo-bifemoral bypass graft.

An 82-year-old woman, who underwent axillo-bifemoral bypass for infrarenal aortic occlusion and peripheral arterial occlusive disease 9 years before, was admitted to our hospital for swelling in the left subclavicular region. Ultrasound examination revealed a leak in the wall of the bypass graft with the formation of a false aneurysm. No signs of infection, either locally or systemically, were observed. Resection of the aneurismal segment with interposition using a Dacron graft was performed. Macroscopic findings during surgery confirmed an intact anastomotic region of the left axillary artery and Dacron graft. Two possible mechanisms for the formation of this false aneurysm, either cumulative stress on the graft over the years or Dacron graft biodegradation, were hypothesized.

Cardiac varix in the right atrium.

A 73-year old man underwent transthoracic and transoesophageal echocardiography and computed tomography, which revealed what appeared to be an asymptomatic primary mobile tumour located in the right atrium. During surgery, the mass was found to be associated with the right atrial septum and was subsequently resected. Histopathology of the mass revealed a cardiac varix with phleboliths. The patient had an uneventful postoperative course and no signs of recurrence at the 10-month follow-up.

Successful usage of extracorporeal membrane oxygenation as a bridge therapy for acute pulmonary embolism between hospitals.

A 50-year-old man presented to a nearby hospital with loss of consciousness. Investigation revealed thrombus formation at the tricuspid valve. Due to suspected pulmonary embolism, the patient underwent contrast-enhanced computed tomography during which he went into a shock with sudden drop in functional oxygen saturation (SpO(2)). Extracorporeal membrane oxygenation (ECMO) was introduced for cardiovascular and respiratory support, and he was transferred to our hospital for further treatment. The patient was treated by surgical thromboembolectomy and was dismissed from the hospital without major complications. We have experienced a case where ECMO was successfully used for cardiovascular and respiratory support, serving as a bridge therapy between hospitals.

The efficacy of intravenous milrinone in left ventricular restoration.

PURPOSE: The aim of this study was to clarify the efficacy of intravenous milrinone in postoperative care for patients following left ventricular (LV) restoration (LVR). METHODS: Fourteen patients who had ischemic cardiomyopathy with an LV ejection fraction (LVEF) of less than 0.30 and an LV end-systolic volume index of more than 100 ml/m2 underwent coronary artery bypass grafting and concomitant LVR. The patients received perioperative management with continuous infusions of 0.5 microg/kg/min milrinone that were started at the induction of a cardiopulmonary bypass (CPB). The perioperative course and outcome of these patients were retrospectively compared with those of matched LVR patients (n = 14) without milrinone administration during perioperative management. RESULTS: The preoperative LV end-diastolic pressure (26.3 mmHg vs. 15.4 mmHg) and early diastolic filling velocity/atrial filling velocity ratio (4.1 vs. 2.1) in the milrinone patients were significantly worse than those in the control. Even though the preoperative LV function in each patient demonstrated to be extremely poor, the perioperative hemodynamic variables were stable. The administered doses of dobutamine (4.01 vs. 5.81 microg/kg/min) and epinephrine (0.017 vs. 0.038 microg/kg/min) at the end of CPB were significantly lower in the milrinone patients compared to control. CONCLUSION: In those patients who underwent LVR because of ischemic cardiomyopathy, the administration of milrinone achieved safe perioperative management for stable hemodynamics and reduced the postoperative doses of dobutamine and epinephrine.

The 17-mm St. Jude Medical Regent valve is a valid option for patients with a small aortic annulus.

BACKGROUND: When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern. Such prosthesis-patient mismatch may affect postoperative clinical status and survival. We investigated the outcomes of isolated aortic valve replacement performed with a 17-mm mechanical prosthesis in patients with aortic stenosis. METHODS: Twenty-three patients with aortic stenosis (mean age, 74.6 +/- 6.3 years) underwent isolated aortic valve replacement with a 17-mm St. Jude Medical Regent prosthesis. Mean body surface area was 1.41 +/- 0.13 m(2). Preoperative echocardiography yielded a mean aortic valve area of 0.36 +/- 0.10 cm(2)/m(2), a mean left ventricular-aortic pressure gradient of 68.4 +/- 25.3 mm Hg, and a mean left ventricular mass index of 200 +/- 69 g/m(2). RESULTS: There was no operative mortality, and there were no valve-related events. Echocardiography at 14.0 +/- 10.0 months after aortic valve replacement showed a significant increase in the mean effective orifice area index (0.95 +/- 0.24 cm(2)/m(2)), decrease in the mean left ventricular-aortic pressure gradient (17.4 +/- 8.2 mm Hg), and decrease in the mean left ventricular mass index (124 +/- 37 cm(2)/m(2)). Prosthesis-patient mismatch (effective orifice area index < 0.85 cm(2)/m(2)) was present in 8 patients at discharge. In these patients as well as in those without prosthesis-patient mismatch, the left ventricular mass index decreased remarkably during follow-up. CONCLUSIONS: Aortic valve replacement with a 17-mm Regent prosthesis appears to provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus. Remarkable left ventricular mass regression during follow-up was achieved irrespective of the effective orifice area index at discharge.

Aortic valve replacement for aortic regurgitation in a patient with left ventricular noncompaction.

We present a case of a 61-year-old man who underwent aortic valve replacement for aortic regurgitation complicated with left ventricular noncompaction. The pathogenesis of this condition remains unknown. In advanced form, left ventricular noncompaction produces marked disability and carries a poor prognosis. We underscore that familiarity with this disease entity will help to stimulate early diagnosis and timely treatment when necessary.

Patency of distal false lumen in acute dissection: extent of resection and prognosis.

We assessed the hypotheses that extension of aortic replacement would reduce the patency of the false lumen of the descending aorta and that postoperative patency of the false lumen would result in poor prognosis. One hundred and twenty-four consecutive patients underwent surgical repair for acute type A acute dissection on an emergency basis. Among the 124 patients, 89 patients had De Bakey type I dissection. Among the patients with De Bakey type I dissection, the false lumen of the descending aorta was preoperatively patent in 52 patients. Distal extent of aortic replacement was ascending aorta in 16 patients, hemiarch in 15 patients, partial arch in seven patients, and total arch in 11 patients. Patency of the false lumen was not influenced by distal extent of the aortic replacement. In a one-year follow-up, the maximum diameter of the descending aorta with patent false lumen had increased significantly than that with closed false lumen. Survival rates were 96% at one year and 67% at five years in the patients with patent false lumen and no mortality in the patients with closed false lumen. Patency of the false lumen was not influenced by extension of aortic replacement and associated with poor prognosis.

Progressive congestive heart failure due to common iliac arteriovenous fistula: a case report.

Arteriovenous shunt is one of the causes of heart failure, but heart failure caused by common iliac arteriovenous fistula is relatively rare. A 64-year-old man who developed acute heart failure due to venous perforation of a common iliac aneurysm and also had bilateral aneurysms (diameter 58 mm) was referred to our department. On admission, the patient complained of dyspnea and swollen left leg, so diuretic agent was administered to treat the heart failure. Cardiac catheterization showed a shunt rate of 80.6%, as well as 5.0 Qp/Qs and O2 step-up across perforation of the common iliac vein. Despite the therapy, pleural effusion and ascites exacerbated, and the heart failure became difficult to control, so surgical treatment was performed. The aneurysm was replaced with an artificial vessel, and the fistula was closed by direct suturing. Postoperatively, the symptoms disappeared, and the patient is in good health.