[Concomitant Surgery for Symptomatic Severe Carotid Artery Stenosis and Aortic Valve Stenosis with Contralateral Internal Carotid Artery Occlusion:A Case Report].

We report a case of concomitant carotid endarterectomy(CEA)and aortic valve replacement(AVR)for symptomatic severe carotid artery and aortic valve stenosis(AS). A 77-year-old man, presented to our hospital with AS complicated by right internal carotid artery(ICA)stenosis and left ICA occlusion, seeking treatment for AS. He suffered from left hemiparesis, and diffusion-weighted magnetic resonance imaging(MRI)showed multiple ischemic lesions in the right cerebral hemisphere. He was admitted to our neurosurgical department and received treatment for acute cerebral infarction caused by severe right ICA stenosis. The symptomatic severe right ICA stenosis was an indication for surgical treatment, but simple carotid revascularization of the stenosed ICA was considered to be deteriorated the cardiac function due to untreated AS. Thus, we decided to perform concomitant carotid and valvular surgery. The patient underwent a combined CEA and AVR procedure with the introduction of an intraoperative intra-aortic balloon pump. His postoperative course was uneventful even 12 months after the surgery. Management and surgical strategies for patients with concomitant ICA stenosis and AS continue to be controversial subjects. Combined carotid and cardiac valve surgery is considered to be effective in such cases, and we discuss its implications and review of literature.

[L-shaped Partial Upper Sternotomy Approach for Aortic Valve Replacement].

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

Successful surgical treatment of traumatic sternal fracture with extensive mediastinal abscess and concomitant mitral valve endocarditis: a case report.

BACKGROUND: A traumatic sternal fracture with extensive mediastinal abscess and concomitant native valve endocarditis is an extremely rare but catastrophic situation. CASE PRESENTATION: For 2 weeks, the co-infected patient was treated with aggressive debridement for the mediastinitis, change of vacuum-assisted closure therapy dressings, vegetectomy and valve repair through lower partial sternotomy, and delayed primary wound closure. CONCLUSIONS: To the best of our knowledge, this successful staged strategy has not been previously reported. We believe that our quick decision about repeated surgical interventions and preservation of the manubrium led to a favorable result.

[Aortic root replacement with the freestyle stentless bioprosthesis for infective endocarditis associated with aortic annular destruction].

Treatment of infective endocarditis (IE) associated with aortic annular destruction remains a formidable surgical challenge. Discussions about the optimum modality for reconstruction are still continuing. In such severe endocarditis, we have performed aortic root replacement using the Freestyle stentless bioprosthesis with the full root technique. From 2005 through 2012, 11 patients who had aortic valve endocarditis with annular destruction underwent aortic root replacement at our institute. All of them were treated with the Freestyle stentless bioprosthesis. Their mean age was 69.9 years, and 8 patients were men. Two patients had native valve endocarditis and 9 patients had prosthetic valve endocarditis. Despite appropriate antibiotic therapy, 3 patients required emergency surgery because of hemodynamic deterioration. In-hospital death occurred in 1 patient due to progressive hemodynamic failure. The 10 hospital survivors were followed up for a mean of 27.7±23.1 months (range 5 to 82). Although late death occurred in 2 patients, recurrent IE was not observed in any patients during the follow-up. The results of our study suggest that the Freestyle stentless bioprosthesis could be an excellent alternative to a homograft in the treatment of infective endocarditis associated with aortic annular destruction.

[Primary cardiac angiosarcoma in the right atrium with cardiac tamponade].

Primary cardiac angiosarcoma is very rare with an incidence of 0.0017∼0.19% in collected autopsy series, and its prognosis has been reported as being extremely poor( average survival of 6∼9 months). A 56-year-old man was referred to our hospital with cardiac tamponade caused by right atrial angiosarcoma, after initially being misdiagnosed as acute type A dissection. Echocardiography and chest computed tomography (CT) revealed a pedunculated tumor with a broad base which was originating from the right atrial wall and extended into atrio-ventricular (AV) groove. The tumor was completely resected, and a bovine pericardium patch was used for cardiac reconstruction. Histological examination showed angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery,was given postoperative radiotherapy and chemotherapy. He died of multiple systemic metastases 14 months postoperatively despite of multidisciplinary treatment. We discuss the therapeutic strategies available for this highly malignant cardiac tumor.

[Completion bentall procedure after aortic valve replacement].

A 51-year-old man, who had undergone aortic valve replacement with a mechanical valve 30 years ago, was referred to our hospital due to acute type A aortic dissection. Pre- and intra-operative echocardiographic evaluation showed no evidence of valve dysfunction or paravalvular leak. Intraoperative inspection revealed a thin pannus covering the leaflet housing of the mechanical valve, which we easily removed. We performed aortic root replacement while leaving the valve in situ, and total aortic arch replacement using elephant trunk technique under hypothermic circulatory arrest. He was discharged from the hospital 31 days after operation and retains normal valve function. For patients with aneurysms and acute type A aortic dissection having aortic valve prosthesis that does not require replacement, the completion Bentall procedure is a more secure and safer repair than complete aortic root reconstruction.

Improvement of liver function after surgery for Budd-Chiari syndrome.

PURPOSE: We evaluated the relationship between liver histology and postoperative improvement of liver function after surgery for Budd-Chiari syndrome (BCS). METHODS: Over a period of 23 years, we operated on 46 patients with BCS by reconstructing the occluded inferior vena cava (IVC) and reopening as many occluded hepatic veins as possible. We divided the patients into a liver cirrhosis group (group I, n = 30) and a hepatic fibrosis or liver congestion group (group II, n = 16), and compared the ages, duration of illness, preoperative liver function, changes in liver function, and changes in esophageal varices (EV). RESULTS: There were no hospital deaths. In group I the patients were older, and the duration of illness was longer. The group I patients also had a lower thrombotest percentage and a higher serum ammonia. The indocyanine green clearance (ICG) test showed more remarkable improvement in liver function in group II. The rate of disappearance of EV was also higher in group II. CONCLUSION: Surgery during the early stage of BCS is important in improving postoperative liver function.

Malignant fibrous histiocytoma of the heart complicated by factor XI deficiency in a Jehovah's Witness patient.

We describe a 16-year-old girl with malignant fibrous histiocytoma (MFH) of the heart complicated by factor XI deficiency. The preoperative diagnosis was left atrial myxoma. We decided to perform the operation owing to a normal bleeding time. Operative findings suggested a malignant tumor. The patient was a Jehovah's Witness, and extensive excision was not performed because blood transfusion was not allowed. We resected as much of the tumor and left atrial appendage as possible. The pathologic diagnosis was MFH. Excessive bleeding was not observed during the operation. Bleeding time helps to determine whether a surgical procedure is indicated in patients with factor XI deficiency.