Severe Aortic Regurgitation Due to Aortic Valve Injury During Percutaneous Coronary Intervention.

Iatrogenic acute aortic regurgitation (AR) is an uncommon condition, and its presentation as severe AR following coronary angiography or percutaneous coronary intervention (PCI) is exceedingly rare. We report a case of iatrogenic severe AR resulting from aortic valve injury caused by manipulation of the guiding catheter during PCI.

[Acute Aortic Dissection Escaping Cardiac Tamponade due to Congenital Pericardial Defect:Report of a Case].

The natural course of Stanford type A acute aortic dissection (AAAD) has a poor prognosis. Early diagnosis is crucial, but in clinical practice some patients do not have typical symptoms, leading to a delay in diagnosis. We encountered a patient who complained only of shoulder pain and moderate respiratory distress. A chest computed tomography( CT) examination showed a dilated ascending aorta and a massive left hemothorax with minimal pericardial effusion. Intraoperative findings revealed aortic dissection of the ascending aorta and a congenital defect on the left pericardium. We performed graft replacement of the aortic root and ascending aorta. Usually, cardiac tamponade is a fatal complication of AAAD. However, in this case, the congenital pericardial defect drained the hemorrhage into the thoracic cavity and relieved cardiac tamponade. AAAD with a congenital pericardial defect may present clinically atypical. In this case, the patient could be saved by surgery without developing circulatory failure due to cardiac tamponade.

A Long-Term Survival Case of Coronary Artery Intimal Sarcoma.

Primary cardiac sarcomas are rare diseases with very poor prognoses. In this report, we present a case of coronary artery intimal sarcoma in a patient who survived for a long time after diagnosis. A 57-year-old female underwent percutaneous coronary intervention of the right coronary artery due to acute myocardial infarction caused by thrombotic occlusion and was diagnosed as having coronary artery intimal sarcoma. She underwent surgical resection and coronary artery bypass surgery of the artery, cryothermy coagulation, and postoperative adjuvant chemotherapy for 1 year. After 3 years, focal recurrence was detected in the caudal region of the left ventricular inferior wall. Radiotherapy was performed. The tumor shrank significantly after radiotherapy. Four years later, there was no significant abnormal uptake on positron-emission tomography/computed tomography. At 7 years after diagnosis, when this case report was submitted, the patient was alive and her performance had maintained a good status. Intimal sarcoma occurring in a coronary artery is extremely rare. The efficacy of treatments for cardiac intimal sarcoma, which include surgical resection, chemotherapy and radiotherapy, has been reported to be limited. To the best of our knowledge, this is the first report of a case of coronary artery intimal sarcoma with long-term survival after comprehensive therapies including surgical resection and radiotherapy.

Acute mitral valve endocarditis at the 24th gestational week.

Infective endocarditis during pregnancy and subsequent cardiac surgery are rare and carry a high mortality risk for both the mother and fetus. We report our experience with a previously healthy, 22-year-old woman affected by acute active mitral endocarditis due to Streptococcus gordonii at the 24th gestational week, who wished to continue with the pregnancy. Due to cardiogenic shock, an intra-aortic balloon pump was inserted. Our patient successfully underwent mitral valve replacement with normothermic high-flow cardiopulmonary bypass and continuous intraoperative fetus monitoring. She delivered a 2524-g baby vaginally at the 38th gestational week. Both the mother and child were confirmed to be doing well at the 1-year follow-up. Although this was the first case, urgent cardiac surgery and a subsequent childbirth went well by prompt decision of each department.

Surgery for tricuspid regurgitation in a case of anomalous systemic venous return.

A 75-year-old woman presented with severe tricuspid regurgitation requiring surgical repair. She had extremely rare anomalies in systemic venous return in spite of situs solitus: persistent left superior vena cava with absent right superior vena cava, infrahepatic inferior vena cava interruption, and hemiazygos continuation to a persistent left superior vena cava. These unusual systemic venous anomalies had significantly enlarged the coronary sinus, and the stretched coronary sinus orifice changed the geometry of the tricuspid annulus and triggered tricuspid regurgitation. There were technical difficulties in establishing cardiopulmonary bypass and achieving successful tricuspid valve repair.

Decreased Serum Levels of High Mobility Group Box 1 (HMGB-1) after Graft Replacement or Stenting of Abdominal Aortic Aneurysm.

BACKGROUND: High-mobility group box 1 (HMGB-1) is a key substance mediating inflammation and development of atherosclerotic lesions (ALs), including abdominal aortic aneurysms (AAA). Serum levels of HMGB-1 are increased in patients with AAA than those in normal controls because the ALs in AAAs secrete HMGB-1. We therefore postulate that the serum HMGB-1 level should decrease after endovascular aortic repair (EVAR) or open aortic repair (OAR). However, there is no evidence of this in the literature. The purpose of this study was to investigate the changes in HMGB-1 levels after surgical intervention for AAA. We also aimed to determine if the HMGB-1 levels varied between the two procedures. METHODS: Serum HMGB-1 levels were determined in 24 patients with AAA and 25 healthy controls. Twelve of the 24 AAA patients underwent EVAR, whereas the other half underwent OAR. The relationship between HMGB-1 levels and presence of AAA or influence of operative methods on the serum HMGB-1 level were prospectively investigated. RESULTS: Serum HMGB-1 levels in AAA patients were significantly higher than those in healthy controls (9.4 ± 5.7 vs. 4.1 ± 2.0 ng/mL, P < 0.01). The serum HMGB-1 levels in both the EVAR group and the OAR group were significantly decreased from baseline at both 3 mo and 1 y after surgery. CONCLUSIONS: Removal or isolation of AL via surgical intervention significantly decreases serum HMGB-1 levels. The significant postoperative reduction in HMGB-1 levels suggests that important endocrinological changes occur after surgical treatment of AAA.

[Delayed Diagnosis of Aortic Dissection Following Thrombolytic Therapy in a Patient with Acute Ischemic Stroke;Report of a Case].

Diagnosis of aortic dissection complicating cerebral ischemic stroke is difficult. A 60-year-old patient presented at an emergency department of a hospital with a sudden development of left-sided weakness, but without chest pain. During administration of recombinant tissue plasminogen activator with diagnosis of cerebral infarction, he developed symptomatic hypotension and was transferred to our hospital. His chest computed tomography revealed Stanford type A aortic dissection. Replacement of the ascending aorta and aortic arch was successfully performed on the 4th day.

Effect of inhibition of glycogen synthase kinase-3 on cardiac hypertrophy during acute pressure overload.

OBJECTIVE: A large number of diverse signaling molecules in cell and animal models participate in the stimulus-response pathway through which the hypertrophic growth of the myocardium is controlled. However, the mechanisms of signaling pathway including the influence of lithium, which is known as an inhibitor of glycogen synthase kinase-3beta, in pressure overload hypertrophy remain unclear. The aim of our study was to determine whether glycogen synthase kinase-3beta inhibition by lithium has acute effects on the myocyte growth mechanism in a pressure overload rat model. METHODS: First, we created a rat model of acute pressure overload cardiac hypertrophy by abdominal aortic banding. Protein expression time courses for beta-catenin, glycogen synthase kinase-3beta, and phosphoserine9-glycogen synthase kinase-3beta were then examined. The rats were divided into four groups: normal rats with or without lithium administration and pressure-overloaded rats with or without lithium administration. Two days after surgery, Western blot analysis of beta-catenin, echo-cardiographic evaluation, left ventricular (LV) weight, and LV atrial natriuretic peptide mRNA levels were evaluated. RESULTS: We observed an increase in the level of glycogen synthase kinase-3beta phosphorylation on Ser 9. A significant enhancement of LV heart weight (P < 0.05) and interventricular septum and posterior wall thickness (P < 0.05) with pressure-overloaded hypertrophy in animals treated with lithium were also observed. Atrial natriuretic peptide mRNA levels were significantly increased with pressure overload hypertrophy in animals treated with lithium. CONCLUSIONS: We have shown in an animal model that inhibition of glycogen synthase kinase-3beta by lithium has an additive effect on pressure overload cardiac hypertrophy.

Pharmacokinetic analysis of flomoxef in children undergoing cardiopulmonary bypass and modified ultrafiltration.

OBJECTIVE: Cardiopulmonary bypass (CPB) induces changes in the pharmacokinetics of drugs. The purpose of this study was to model the pharmacokinetics of flomoxef, a cephalosporin antibiotic, in pediatric cardiac surgery. METHODS: Each patient received a flomoxef dose of 30 mg/kg as a bolus after the induction of anesthesia and an additional dose (1 g for a child weighing < 10 kg, 2 g for > or = 10 kg) was injected into the CPB prime. Modified ultrafiltration (MUF) was routinely performed. Blood samples, urine, and ultrafiltrate were collected. In seven patients (group I), serum flomoxef concentration-time courses were analyzed by a modified two-compartment model. Utilizing the estimated parameters, serum concentrations were simulated in another eight patients (group II). RESULTS: The initiation of CPB resulted in an abrupt increase in serum flomoxef concentrations in group I; however, concentrations declined biexponentially. The amount of excreted flomoxef in the urine and by MUF was 47% +/- 8% of the total administered dose. In group II, an excellent fit was found between the values calculated by the program and the observed serum concentrations expressed; most of the performance errors were <1.0. There was no difference in any kinetic parameter between group I and groups I + II (n = 15). CONCLUSION: The pharmacokinetics of flomoxef in children undergoing CPB and MUF were well fitted to a modified two-compartment model. Using the kinetic data from this study, the individualization of dosage regimens for prophylactic use of flomoxef might be possible.

A rare cause of dissection of ascending aorta after aortic valve replacement.

We present a 78-year-old man who developed Stanford type A aortic dissection seven years after aortic valve replacement. At the previous operation, the diameter of the ascending aorta was 40 mm. Three years later, computed tomography revealed the diameter to have expanded to 50 mm. Four years later, the patient developed aortic dissection with entry at the ascending aorta, and a graft replacement was performed.

Mitral-aortic intervalvular pseudoaneurysm with ventricular septal defect.

A 35-year-old woman was found on echocardiography to have a pseudoaneurysm of the mitral-aortic intervalvular fibrosa, residual ventricular septal defect, and aortic regurgitation. She had undergone surgical closure of a ventricular septal defect at age 7 and was found to have residual shunt several years later. She had been followed nonsurgically and had symptoms of cardiac failure during her 2 pregnancies. The pseudoaneurysm and the septal defect were successfully repaired.

Cosmetic approach for correction of simple congenital heart defects in female patients.

OBJECTIVE: Much more concern is recently paid to the cosmetics when simple congenital heart defect is repaired. Here we present the reversed U-shaped skin incision with lower partial sternotomy for juvenile or adult female patients. METHODS: Four patients with atrial septal defect (ASD) and one patient with ventricular septal defect underwent the operation with this method. Patients' ages ranged from 5 to 46 years old. RESULTS: Postoperative recovery in all cases was uneventful. Only the middle portion of the operative scar was visible when the breast was well developed. The scar was completely covered by the brassiere. A numbness of the upper medial portion of the left breast was recognized in one initial patient, who underwent ASD closure and concomitant right-side Maze procedure, necessitating a wider dissection than that used for other patients. CONCLUSION: A reversed U-shaped skin incision with a lower sternotomy could provide relatively comfortable operative fields for cardiac surgeons, and be cosmetically appealing to female patients who require a repair of simple congenital heart defect.

Successful trapdoor technique for two separate coronary ostia in a single aortic sinus in arterial switch operation for complete transposition of the great arteries.

Two separate origins of coronary arteries from a single aortic sinus remains a rare but significant congenital anomaly for surgical repair. We experienced a case of a newborn with complete transposition of the great arteries with unusual coronary arteries with two separate ostia positioned close to each other in the same right aortic sinus, and the left coronary artery coursing behind the pulmonary artery. No description of this case in the English literature has been published to our knowledge. Precise anatomical diagnosis was made at operation, and these anomalous coronaries were successfully transferred by the trapdoor technique with delicate adjustment after transfer. Postoperative catheterization and angiogram done 14 months after the arterial switch operation showed no coronary artery stenosis along with normal chamber pressures. The infant is asymptomatic and shows normal development for his age.

Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome.

OBJECTIVE: Pulmonary overcirculation through a systemic-pulmonary shunt has been one of the major causes of early death after the Norwood procedure. To avoid this lethal complication, we constructed a right ventricle-pulmonary shunt in first-stage palliation of hypoplastic left heart syndrome. METHODS: Between February 1998 and February 2002, 19 consecutive infants, aged 6 to 57 days (median, 9 days) and weighing 1.6 to 3.9 kg (median, 3.0 kg), underwent a modified Norwood operation with the right ventricle-pulmonary artery shunt. The procedure included aortic reconstruction by direct anastomosis of the proximal main pulmonary artery and a nonvalved polytetrafluoroethylene shunt between a small right ventriculotomy and a distal stump of the main pulmonary artery. The size of the shunt used was 4 mm in 5 patients and 5 mm in 14. RESULTS: All patients were managed without any particular manipulation to control pulmonary vascular resistance. There were 17 survivors (89%), including 3 patients weighing less than 2 kg. Two late deaths occurred due to obstruction of the right ventricle-pulmonary artery shunt. Thirteen patients underwent a stage II Glenn procedure after a mean interval of 6 months, with 2 hospital deaths. To date, a stage III Fontan procedure has been completed in 4 patients. Overall survival was 62% (13/19). Right ventricular fractional shortening at the last follow-up (3-48 months after stage I) ranged from 26% to 43% (n = 13, mean, 33%). CONCLUSION: Without delicate postoperative management to control pulmonary vascular resistance, the modified Norwood procedure using the right ventricle-pulmonary shunt provides a stable systemic circulation as well as adequate pulmonary blood flow. This novel operation may be particularly beneficial to low-birth-weight infants with hypoplastic left heart syndrome.