[Distal Stent Graft-induced New Entry after Total Arch Replacement for the Aortic Dissection:Report of a Case].

A 73-year-old man after total arch replacement with open stent graft (OSG) technique for Stanford type B aortic dissection was found to have expanding descending aortic aneurysm. Contrast-enhanced computed tomography (CT) showed distal stent graft-induced new entry (distal SINE). We successfully performed additional thoracic endovascular aortic repair (TEVAR). The determinants of distal SINE are reported to be excessive distal oversizing and spring back force on the distal end of the stent graft, which might make the stress for descending aorta. We also found that the angle between distal end of the stent graft and the horizontal line of the body was changed. The angle when distal SINE occurred was smaller than that of when it was placed. Appropriate size selection and positioning of stent graft might reduce the risk of distal SINE events.

[Modified Warden Procedure for Correction of Partial Anomalous Pulmonary Venous Connection and Sinus Venosus Atrial Septal Defect in an Adult].

A 32-year-old woman was referred to our hospital for the surgical indication of sinus venosus-type atrial septal defect. Preoperative computed tomography scan revealed that the right upper pulmonary vein returned to the high superior vena cava. We performed a modified Warden procedure using a pedicle flap of the right atrial appendage along with a fresh autologous pericardium. Her postoperative course was uneventful with no venous obstruction or sinus node dysfunction. This technique is a useful surgical option for a partial anomalous pulmonary venous connection especially in adults.

[Postinfarction Ventricular Septal Perforation Treated with the Sandwich Method Using a Right Ventricular Approach;Report of a Case].

The patient was a 75-year-old man who presented to our hospital with complaints of palpitation and a cold sensation. Echocardiography revealed ventricular septal perforation(VSP) at the base of the posterior septum. As his hemodynamic condition was stable, patch closure of the VSP was performed on the 50th hospital day after fibrosis at the infarction site developed. Under cardiac arrest, an incision directed toward the cardiac apex was made at the base of the right ventricular inferior wall. Closure of the VSP was performed using double-patch sandwich technique:a bovine pericardial patch on the left, and a Dacron patch on the right ventricular side. The postoperative course was uneventful.

[A Single-knot Lock Procedure for Adjustment of Artificial Chordae in Mitral Valve Repair].

We describe a simple and reproducible technique for adjustment of neochordal length in mitral valve repair with a single-knot lock procedure. A small loop with polytetra fluoroethylene(CV-4)is secured on the papillary muscle as an anchor for the neochordae. A needle with CV-5 suture is passed through the anchor loop, and both ends of the suture are passed through the free edge of the prolapsed mitral leaflet. A single knot is made on the leaflet with the 2 ends of each suture thread, and the ends of each pair of suture threads are secured with small hemostatic clamps. The hemostatic clamps are suspended over the edge of the wound to apply traction to the single knot. The knot is locked with this tension and the friction between the threads. The saline injection test is applied, and the height of the artificial chordae is adjusted by sliding the knot to the appropriate position. After valve competency is obtained, the knot is held by curved hemostatic forceps, and the threads of the suture are tied on the leaflet. This technique for adjustment of neochordal length is quick, reliable, reproducible, and increases the technical possibilities for mitral valve repair.

[Technique to Reinforce Double-barreled Distal Aortic Anastomosis in the Repair of Aortic Dissection].

We describe a technique to reinforce a double-barreled aortic anastomosis in the repair of chronic aortic dissection. After distal aortic resection was carried out, an intimal flap was incised lineally 1 cm in width along with its margin. This intimal band was reapproximated to the adventitia which supported the false lumen. The wedge-shaped excision was made on the residual intimal flap to maintain blood flow to both the true and false lumens. Two felt strips were circumferentially placed inside and outside of the aortic edge, and the layers were sandwiched together with monofilament sutures. Finally, the prosthetic graft was anastomosed to the reinforced aortic stump with continuous suture. If the length of the intimal edge was shorter than that of the dissected adventitia, the intima was incised in a long, triangular shape from its base to form 2 ligulate flaps. The flaps were then slid together and attached to the corresponding adventitia, and the aortic stump was reinforced using the sandwich technique. This technique may be an effective and safe method for reinforcement of a double-barreled aortic anastomosis in the repair of chronic aortic dissection.

[Novel Device for Creating Multiple Artificial Chordae Loops in Mitral Valve Repair].

A novel device to create multiple artificial chordae loops for mitral repair is developed. The device consists of a circular metal base with a removable central rod on one end, which can easily be attached or removed by screwing into a hole located on the base, and 51 fixed rods placed radially around the central rod at distances of 10~60 mm from the central rod. A needle with CV-4 e-polytetrafluoroethylene suture is passed through a pledget, and the suture is looped from the central rod around the fixed rod located at the desired loop length. The needle is then passed back through the pledget. The suture is tied over the pledget, bringing it in contact with the central rod. When multiple loops of various lengths are required, different fixed rods located at distances corresponding to the required loop lengths are used. Following creation of the necessary loops, the central rod is unscrewed, and the loops are released from the device. Construction of artificial chordae with this device is quick, reliable, reproducible, and increases the technical possibilities for mitral valve repair.

Acute aortic regurgitation due to aortic dissection confined to the sinus of Valsalva.

A 34-year-old man with severe heart failure was diagnosed with acute aortic regurgitation (AR) by transthoracic echocardiography (TTE). However, this differential diagnosis was incomplete. Only transesophageal echocardiography (TEE) revealed an intimal flap, leading to a diagnosis of Stanford type A aortic dissection. No abnormal findings were observed in the ascending aorta by contrast-enhanced computed tomography (CT). Aortic dissection confined to the sinus of Valsalva has rarely been reported; however, TEE should still be considered for the differential diagnosis of acute AR, even if there is no evidence of dissection by TTE or contrast-enhanced CT.

Effect of landiolol hydrochloride after off-pump coronary artery bypass.

OBJECTIVES: many studies have shown that oral beta blockers reduce the incidence of atrial fibrillation after coronary artery bypass. The goal of this study was to determine whether landiolol, an intravenous beta blocker, reduces the incidence of atrial fibrillation after off-pump coronary artery bypass. METHODS: 39 consecutive patients were given landiolol after coronary artery bypass, and 20 who were not given landiolol served as a control group. Landiolol was intravenously administered at 1 µg.kg(-1).min(-1) in the intensive care unit. RESULTS: the mean dose of landiolol was 2.3 ± 1.2 1 µg.kg(-1).min(-1). The incidence of atrial fibrillation during intensive care unit stay was significantly lower in the landiolol group compared to the control group: 2.6% (1/39) vs. 20% (4/20). Heart rate after landiolol administration was significantly lower than that before administration, whereas landiolol had no effect on blood pressure. C-reactive protein and creatine kinase levels 7 days after surgery were significantly lower in the landiolol group. CONCLUSION: continuous administration of landiolol at a low dose after off-pump coronary artery bypass reduced the incidence of atrial fibrillation.

Diaphragmatic hernia following coronary artery bypass surgery with the right gastroepiploic artery: case report and literature review.

We report an unusual case of intrapericardial diaphragmatic hernia 2 years after coronary artery bypass surgery with the right gastroepiploic artery. Herniation through the orifice created for the right gastroepiploic artery caused small bowel strangulation and secondary volvulus requiring extensive small bowel resection due to acute mesenteric ischemia. This case highlights the importance of careful operative management of coronary artery bypass surgery with the right gastroepiploic artery and increases awareness of this rare but potentially fatal complication.

Injury to the tricuspid valve and membranous atrioventricular septum caused by huge calcified right ventricular myxoma: report of a case.

A 64-year-old female, admitted because of severe dyspnea on exertion and facial edema, showed echocardiographic findings of a large tumor in the right ventricle (RV). Echocardiography revealed a cardiac mass extending from the RV across the tricuspid valve into the right atrium, synchronized with the cardiac cycle, and severe tricuspid regurgitation was apparent. The mass was removed under cardiopulmonary bypass. It measured 7 x 5 x 5 cm with diffuse superficial calcification and arose from the posterior wall of the RV, just under the tricuspid valve ring, with a short pedicle. During the same procedure, after the successful excision of the tumor, small atrial and ventricular septal defects were found that had been caused by the tumor and these were closed directly. The tricuspid valve was repaired with valvuloplasty, chordoplasty and annuloplasty. The microscopic findings were of typical myxoma; however, a right ventricular myxoma protruding into the right atrium is exceedingly rare.

Pathogenetic significance of myxomatous degeneration in fenestration-related massive aortic regurgitation.

BACKGROUND: Aortic valvular regurgitation has several mechanisms and the present study investigated its clinicopathological correlations with aortic valve fenestration. METHODS AND RESULTS: Six male patients with massive regurgitation and enlarged fenestrations or ruptured fenestrated fibrous cords underwent aortic valve replacement. The clinicopathological features showed many similarities. Four cases had family histories of aortic regurgitation. All six patients showed moderate to severe myxomatous degeneration of the aortic valve and enlargement of aortic annulus. Four patients had 1-2 ruptured fibrous cords, located at the right coronary cusp. Echocardiographic examinations showed an abnormal fibrous cord attached to the prolapsing cusp in 3 cases with ruptured fenestrated valve and detailed examination by transesophageal echocardiography showed an intact fenestrated fibrous cord at the commissure in 1 case. CONCLUSION: Extensively fenestrated cusps with an enlarged aortic annulus because of myxomatous degeneration can cause chronic regurgitation or sudden deterioration after rupture of the fibrous cord. There is an increasing incidence of fenestration-related aortic regurgitation in the Japanese population. An important pathogenetic factor in male patients is myxomatous degeneration of the aortic cusp and annulus.