A knot-pusher technique with hand-tying precision through a mini-thoracotomy.

This study documents the application of a knot-pusher technique via a mini-thoracotomy with the traditional one-handed knot-tying rationale using an existing long-shaft knot-pushing device. This technique achieved the typical hand-tying precision and secured tight knots in minimally invasive cardiac surgery.

Extensive aortic root endocarditis caused ventricular septal rupture.

A 79-year-old man was referred to us for severe cardiac decompensation. Chest radiography showed severe pulmonary edema, and transesophageal echocardiography revealed extensive vegetations on all aortic valve leaflets with severe aortic valve regurgitation, heterogeneous cavities adjacent to the aortic annulus, and ventricular septal rupture into the right-ventricular outflow tract. After extensive debridement of the aortic root (including the infected ventricular septum), the ventricular septum and aortic root were reconstructed using autologous and bovine pericardial patches, and a bioprosthetic stented valve was placed. The postoperative course was uneventful, and he remains recurrence-free 4 years after surgery.

Insulin and glucose infusion could prevent euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter 2 inhibitors.

Perioperative euglycemic diabetic ketoacidosis (euDKA) is a serious adverse effect of sodium-glucose cotransporter 2 inhibitor (SGLT2i) treatment. We observed perioperative euDKA immediately after discontinuing insulin infusion that was started during surgery in a patient with type 2 diabetes mellitus (T2DM) for whom empagliflozin could not be withdrawn before emergency off-pump coronary artery bypass grafting (OPCAB). Insulin infusion that was started during surgery unexpectedly prevented euDKA until its discontinuation. Therefore, we hypothesized that insulin and glucose infusion initiated at the start of emergency surgery in patients receiving SGLT2is prevents perioperative euDKA. We implemented this strategy during emergency OPCAB in another patient with T2DM who received empagliflozin 2 days before surgery and observed that the patient did not develop perioperative euDKA. With the increasing use of SGLT2is, surgeons may encounter more SGLT2i users who require emergency surgeries. The administration of insulin and glucose infusion in advance emergency surgery can prevent perioperative euDKA.

Myocardial ischemia due to radical resection of complex coronary fistulas with giant aneurysms: a case report.

A 56-year-old man underwent surgery for complex coronary artery fistulas with giant coronary aneurysms. This treatment resulted in complications and caused myocardial ischemia of the right ventricular outflow tract, resulting in repeated ventricular fibrillations. The irritability caused by this fetal arrhythmia was improved by the placement of an intra-aortic balloon pump. The case findings suggest that even careful resection of complex coronary fistulas could precipitate myocardial ischemia.

[Double Infectious Aortic Aneurysms Followed by Positron Emission Tomography/Computed Tomography for Evaluation of Infection Control after Simultaneous Thoracic Endovascular Aortic Repair and Endovascular Aortic Repair:Report of a Case].

An 81-year-old male was referred to our institute. His chief complaint was high fever. Computed tomography (CT) angiography demonstrated newly saccular aortic aneurysms at both thoracic and abdominal aorta. We used intravenous antibiotics( ceftriaxone 4 g/day) for seven days. Positron emission tomography (PET)/CT showed active inflammation sign at both chest and abdominal aneurysms. Open surgery for double aortic aneurysms seemed too invasive because of his past medical history. At eighth day after admission, we performed thoracic endovascular aortic repair( TEVAR) and endovascular aortic repair (EVAR) for preventing rupture of aortic aneurysms. After surgery, we continued intravenous antibiotics (ceftriaxone 4 g/day) for 15 days. We changed intravenous antibiotics to oral antibiotics( levofloxacin 500 mg/day). The postoperative course was uneventful. He was discharged at 19th day after surgery. Since surgery, no symptoms of reinfection have been observed at outpatient clinic. PET/CT was useful to evaluate the control of local infection in this case.

Cardiac tamponade due to ruptured coronary-pulmonary artery fistula aneurysm: a case report.

BACKGROUND: Coronary artery fistulas are rare and most commonly asymptomatic; however, they can become enlarged and rupture in some cases. CASE SUMMARY: We report a case of a 51-year-old woman who was brought to our hospital unconscious in an ambulance. Cardiac tamponade caused by the rupture of an aneurismal coronary-pulmonary artery fistula (CPAF) was detected by contrast-enhanced computed tomography and confirmed by invasive coronary angiography. Due to prompt diagnosis and subsequent surgical intervention, the patient's condition was rapidly improved, and she was discharged from the hospital. DISCUSSION: Coronary-pulmonary artery fistula aneurysm rupture requires rapid diagnosis and treatment, and thus, in cases with cardiac tamponade and coronary aneurysm, CPAF aneurysm rupture should be considered.

Postinfarction ventricular septal rupture closure without ventriculotomy.

Postinfarction ventricular septal rupture is a life-threatening complication of acute myocardial infarction. Although some novel techniques of ventricular septal rupture closure have been introduced, they involve ventriculotomy, a procedure that can cause a degree of impairment of the incised ventricle. We describe a case in which we closed a ventricular septal rupture through the tricuspid valve, without ventriculotomy.

[Strategy of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection in Subacute and Chronic Phase;Interval From Onset and Maximum Diameter].

We classified 59 patients who underwent thoracic endovascular aortic repair for uncomplicated type B aortic dissection from April 2008 to April 2016 into 3 groups based on time from onset and maximum aortic diameter:SA (2weeks to 1 year since onset;n=29), C (>1 year since onset;n=17), and D(maximum aneurysm size≥60 mm;n=13). We used the Kaplan-Meier method tso analyze survival, major adverse cardiovascular event and the need for additional treatment. There was no significant difference in outcomes between the SA and C groups (p=0.998) or C and D groups (p=0.279), but the results in group D tended to be consistently inferior. The freedom from aneurysm rupture rate was inferior in this group, with a significant difference between groups C and D (p=0.044). The time from onset to the procedure and maximum aortic diameter were not significantly associated with the longterm outcomes;however, more aortic ruptures occurred in the group with maximum aortic diameter≥60 mm. Simultaneous treatment for re-entry closure or conventional surgical procedures should be considered for such cases.

Prevention of pacemaker-associated contact dermatitis by polytetrafluoroethylene sheet and conduit coating of the pacemaker system.

A 73-year-old female with sick sinus syndrome and atrial fibrillation was implanted with a ventricular demand inhibit pacemaker. She subsequently developed multiple episodes of skin irritation and necrosis. Skin patch testing revealed sensitivity to almost every component of the pacemaker system. The pacemaker was removed and replaced with a new pacemaker in which the generator was covered with a polytetrafluoroethylene (PTFE) sheet and the lead was covered with PTFE conduit. The patient suffered no further episodes of pacemaker-associated contact dermatitis.

Four-dimensional geometric assessment of tricuspid annulus movement in early functional tricuspid regurgitation patients indicates decreased longitudinal flexibility.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is generally caused by the dilation of the tricuspid annulus (TA) and the tethering of tricuspid leaflets; however, it also occurs in patients without dilatation of the TA. The aim of this study was to develop and to use a four-dimensional tracking system, utilizing cardiac magnetic resonance imaging (MRI), and to assess TA flexibility in patients with early FTR without right ventricle dilation as a preliminary investigation for the mechanism of early FTR. METHODS: The structure and movement of the TA were examined in 20 healthy subjects and 19 FTR patients whose right ventricle was not dilated. We analysed the short axis and longitudinal movement of a mid-septal point (S), a mid-lateral point (L), a mid-anterior point (A) and a mid-posterior point (P) on the TA throughout the cardiac cycle. The tethering distance of the tricuspid leaflets and the integrated orbiting volume of the TA were also measured. RESULTS: The TA area (mm(2)) and AP and LS distances (mm) did not differ significantly between the two groups, but the longitudinally moving distances (mm) of the four points were significantly shorter in patients with FTR than in healthy subjects. Also, the mean tethering distance (mm) was significantly longer in patients with FTR than in healthy subjects (9.0 ± 1.5 vs 4.0 ± 1.3, respectively; P < 0.001), and the integrated volume (mm(3)) of the annular moving track, throughout the cardiac cycle, was significantly larger in healthy subjects than in patients with FTR (40 428 ± 10 951 vs 22 967 ± 6079, P < 0.001). CONCLUSIONS: The longitudinal flexibility of the TA in FTR patients was significantly less than that in the healthy subjects, and the tethering of the tricuspid leaflets occurred in FTR patients despite the absence of TA and RV dilation, which can be one triggering factor of early FTR. Four-dimensional geometric assessment, using cardiac MRI and the tracking program that we have developed, is capable of determining TA structure and flexibility.

Cerebral hemorrhage after mitral valve replacement in a patient with active infective endocarditis during the acute phase of a cerebellar infarction: a case report.

A 60-year-old woman presented with a high fever (39°C or higher). Transthoracic echocardiography revealed a large and mobile vegetation on the anterior mitral leaflet with moderate mitral regurgitation. Computed tomography revealed a cerebellar infarction. The large vegetation had extended into the mitral annulus and had become mobile, and furthermore the patient failed with cardiac decompensation. Although the cerebellar infarction was still in the acute phase, we performed a radical resection of the vegetation and infected tissue, annular reconstruction with an autologous pericardial patch, and mitral valve replacement 3 days after admission. After the operation, the patient suffered from subsequent cerebral hemorrhage in the occipital lobe. The patient received medical treatment and was discharged successfully without sequelae.

Redo an aortic valve replacement for bioprosthetic valve destruction in a patient developing Streptococcus bacteremia three years after the initial operation.

A 66-year-old man with a bioprosthetic aortic valve developed Streptococcus bacteremia and was treated with antibiotics. He responded well to this therapy, and no evidence of bioprosthetic valve endocarditis (BVE) was detected at this time. One-and-a-half years after the antibiotic therapy for bacteremia, the patient was referred to our department with a diagnosis of acute cardiac failure. Transthoracic echocardiography revealed torn bioprosthetic valve leaflets with severe aortic regurgitation. A redo aortic valve replacement was undertaken, followed by antibiotic therapy for 6 weeks after the surgery. A histopathological examination of the surgically resected valve suggested a healed infective BVE. No recurrence of bacteremia has been noted since the reoperation.

High-output heart failure caused by arteriovenous fistula long after nephrectomy.

A 70-year-old Japanese woman was admitted to our hospital because of anasarca. At 32 years of age, she had undergone nephrectomy for renal tuberculosis. A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula. Cardiac catheterization disclosed cardiac output of 9.2 l/min and a step-up of oxygen saturation at the renal vein level of the inferior vena cava. Surgical closure of the fistula promptly decreased her cardiac output and improved the heart failure. This is a rare case of an arteriovenous fistula developing long after nephrectomy and causing high-output heart failure.