Impact of the Cardioplegia Interval on Myocardial Protection Using the Modified St. Thomas Solution in Minimally Invasive Mitral Valve Surgery: A Double-Center Study.

It has been reported that a single-dose cardioplegia interval is useful, but the safe interval doses are not clear. We aimed to investigate the impact of the cardioplegia interval on myocardial protection using the modified St. Thomas solution. We included consecutive isolated minimally invasive mitral valvuloplasty procedures (n = 229) performed at a hospital and medical center from January 2014 to December 2020. We compared postoperative peak creatine kinase MB and creatine kinase levels and other indicators between the short (Group S, n = 135; maximum myocardial protection interval <60 minutes) and long (Group L, n = 94; maximum myocardial protection interval ≥60 minutes) interval groups. Propensity score matching was used to adjust for confounders between the two groups. After propensity score matching, Groups S and L contained 47 patients each. Groups S and L did not differ significantly in peak creatine kinase MB (45.8 ± 26.3 IU/L and 41.5 ± 27.9 IU/L, respectively; p = .441) and creatine kinase levels (1,133 ± 567 IU/L and 1,100 ± 916 IU/L, respectively; p = .837) after admission to the intensive care unit on the day of surgery based on propensity score matching. In multivariate analysis, a cardioplegia dosing interval ≥60 minutes was not significantly associated with the maximum creatine kinase MB level after admission to the intensive care unit on the day of surgery (p = .354; 95% confidence interval: -1.67 to 4.65). Using the antegrade modified St. Thomas solution, the long interval dose method is useful and safe in minimally invasive mitral valvuloplasty.

Anomalous systemic arterial supply to the left basal lung with a calcified abnormal vessel: a case report.

BACKGROUND: Anomalous systemic arterial supply to the normal basal segment of the left lower lobe is a congenital abnormality of the lung, frequently and is generally diagnosed at a young age. Surgery is generally recommended if symptoms such as blood sputum or fever are observed. Resection of the abnormal artery is often performed at an early age, with only few reports of surgery being performed at an older age. In addition, to the best of our knowledge, there are no reports on surgical treatment of abnormal calcified vessels to date. Herein, we have presented a case in which a calcified aberrant vessel of lung was resolved surgically. CASE PRESENTATION: A 65-year-old female, previously diagnosed with anomalous systemic arterial supply to the left normal basal segment of the left lung lower lobe of lung was under observation on the basis of being asymptomatic. The patient presented to the emergency room with the chief complaint of blood in the sputum and she was referred to our hospital for a surgery. Computed tomography showed circumferential calcification of the intima of the abnormal vessel, which might have contributed to incomplete resection of the artery if automatic sutures were used. Thus, the abnormal vessel was ligated and dissected using pledgeted 4-0 polypropylene sutures and vessel clips under open thoracotomy followed by left lower lobectomy. The patient was discharged seven days after surgery without any serious surgical complications. CONCLUSIONS: Vascular congenital anomalies of the lung are often operated at a young age presenting due to the associated symptoms. However, even if the disease is discovered incidentally and does not cause any symptoms or calcification in the aberrant artery, early surgical intervention is important due to the possibility of calcification occuring in the future. This can help minimize the degree of surgical invasion.

Primary malignant pericardial mesothelioma presenting with cardiac tamponade.

INTRODUCTION: Primary malignant pericardial mesothelioma is a rare tumor that is very difficult to diagnose. Furthermore, it is a lethal disease, because patients usually have progressed at the time of referral. PRESENTATION OF THE CASE: We report a 44-year-old man with primary malignant pericardial mesothelioma. He was referred to our hospital for the diagnosis and treatment of a massive pericardial effusion and huge tumor. Pericardiocentesis was performed, but we could not obtain definitive diagnosis, and the cardiac tamponade continued along with the signs/symptoms. He required surgical intervention for the diagnosis and treatment. After surgery, his signs/symptoms improved. He received adjuvant therapy, although he died 7 months after surgery. DISCUSSION: Primary malignant pericardial mesothelioma is a rare tumor. The most common signs and symptoms are related to constriction of the heart by the tumor and/or effusion. Even if the pericardial fluid specimen obtained by pericardiocentesis is negative for malignant cells, primary malignant pericardial mesothelioma should be included in the differential diagnosis. Because the malignancy is usually advanced at the time of diagnosis, it has been difficult to cure. Radiation and chemotherapy have been used in addition to surgery, but have been minimally effective. CONCLUSION: The outcome of our patient with pericardial malignant mesothelioma was dismal. The indications for surgical intervention should be carefully considered except for critical cases requiring alleviation of immediate life-threating conditions.

Surgical treatment of a huge hepatic artery aneurysm without revascularization-Case Report.

INTRODUCTION: Hepatic artery aneurysms (HAA) are rare and life-threatening. PRESENTATION OF CASE: We report a case of a 68-year-old man with a huge HAA diagnosed incidentally. Computed tomography showed a huge HAA (67-84 mm diameter). The patient underwent aneurysm resection and ligation of the common and proper hepatic arteries via laparotomy. Revascularization was not performed because intraoperative ultrasound showed pulsatile inflow to the left hepatic lobe. Postoperative cholecystitis and hepatic infarction were temporarily observed. Two months after the previous discharge, cholecystectomy was performed. DISCUSSION: A diameter ≥5 cm of HAA is thought to be rare in arterial aneurysm diseases. There is no consensus in the treatment policy and treatment is selected according to the patient's condition. In this case, we selected open surgery for this patient instead of endovascular surgery due to rupture risks, irregularity and narrowness of vessel structure, and prolonged irradiation-time. If revascularization is not performed at the time of resection, open surgery with cholecystectomy is capable of preventing postoperative cholangitis after resection of HAA, and should be taken into account even if collateral circulation can be confirmed. CONCLUSION: This case highlights the difficulty of managing HAA and provides insight into a successful surgical treatment of HAA without complete revascularization.

Graft protective effect and induction of CD4+Foxp3+ cell by Thrombomodulin on allograft arteriosclerosis in mice.

BACKGROUND: Thrombomodulin (TM) is a promising therapeutic natural anti-coagulant, which exerts the effects to control disseminated intravascular coagulation. However, little is known whether TM on micro-vessels could play an important role in the regulation of intimal hyperplasia. We investigated the vessel-protective effect of TM in the survival of fully major histocompatibility complex (MHC)-mismatched murine cardiac allograft transplantation. METHODS: CBA recipients transplanted with a C57BL/6 heart received intraperitoneal administration of normal saline or 0.2, 2.0, and 20.0 µg/day of TM for 7 days (n = 5, 7, 11, and 11, respectively). Immunohistochemical and fluorescent staining studies were performed to determine whether CD4+Foxp3+ regulatory T cell were generated at 2 and 4 weeks after grafting. Morphometric analysis for neointimal formation in the coronary arteries of the transplanted allograft was conducted at 2 and 4 weeks after grafting. RESULTS: Untreated CBA recipients rejected C57BL/6 cardiac grafts acutely (median survival time [MST], 7 days). CBA recipients exposed with the above doses had significantly prolonged allograft survival (MSTs, 17, 24 and 50 days, respectively). Morphometric assessment showed that intimal hyperplasia was clearly suppressed in the left and right coronary arteries or allografts from TM-exposed recipients 2 and 4 weeks. Immunohistochemical studies at 2 weeks showed more CD4+Foxp3+ cells and lower myocardial damage in the allografts from TM-exposed recipients. Notably, fluorescent staining studies demonstrated that TM-exposed recipients 4 weeks post-engraftment had strong aggregation of CD4+Foxp3+ cells in the intima of the coronary arteries of the cardiac allografts. CONCLUSIONS: TM may prolong the survival of fully MHC-mismatched cardiac allografts through suppressing intimal hyperplasia and inducing the accumulation of regulatory CD4+Foxp3+ cells within coronary arteries.

A case of an elderly man who required repeated repair of a ventricular septal defect and tricuspid rupture after blunt chest trauma.

Several cases of traumatic ventricular septal defect (VSD) have been reported. However, traumatic VSD complicated by tricuspid rupture is rare. We report a case of traumatic VSD with tricuspid rupture who required repeated repair of both conditions. A 69-year-old man was transferred to our hospital for emergent surgical repair of traumatic VSD and tricuspid rupture. Although emergent repair was performed, a new left-to-right shunt and moderate tricuspid regurgitation appeared during his postoperative course. A reoperation was performed 4 months after the first operation. The borders of the defect were very fibrotic and strong compared with those in the first operation. Surgical treatment of traumatic VSD should be postponed in hemodynamically stable patients. When emergent repair is performed, careful follow-up is necessary to diagnose new VSD.

Combination of paeoniae radix and cnidii rhizoma prolonged survival of fully mismatched cardiac allografts and generated regulatory cells in mice.

In previous studies, we have demonstrated that Tokishakuyakusan (TJ-23) can prolong the survival of allogeneic cardiac grafts and induce regulatory T cells. In this study we investigated the effects of Paeoniae radix and Cnidii rhizoma, two components of TJ-23, on alloimmune responses in a murine cardiac transplantation model and whether the two agents have synergistic effect. CBA mice underwent transplantation of a C57BL/6 heart and received oral administration of 2 g/kg/day of Paeoniae radix, Cnidii rhizoma, or the mixture of two agents from the day of transplantation until 7 days afterward. Naïve CBA mice rejected C57BL/6 cardiac graft acutely (median survival time (MST): 7 days). Paeoniae radix and Cnidii rhizoma prolonged C57BL/6 allograft survival (MSTs: 13.5 and 15.5 days, resp.). However, the mixture of two agents prolonged C57BL/6 allograft survival indefinitely (MST > 100 days). Secondary CBA recipients given whole splenocytes from primary combination-treated CBA recipients with B6 cardiac allografts 30 days after grafting had prolonged survival of B6 hearts (MST: 33 days). Flow cytometry studies showed that the CD4(+)CD25(+)Foxp3(+) regulatory cell population was increased in combination-treated recipients. Combination of Paeoniae radix and Cnidii rhizoma induced hyporesponsiveness to fully allogeneic cardiac allografts and may generate CD4(+)CD25(+)Foxp3(+) regulatory cells in our model.

Outcomes of contemporary emergency open surgery for type A acute aortic dissection in elderly patients.

OBJECTIVES: We sought to evaluate surgical outcomes of type A acute aortic dissection in elderly patients. METHODS: Between January 2004 and July 2011, 422 patients underwent emergency open surgery for type A acute aortic dissection at our institution. Of those, 124 patients who were ≥75 years (mean age, 78.6 ± 3.4 years) were reviewed. We also reviewed 26 patients (≥75 years old) who were diagnosed with acute aortic dissection at our institution during the same period but who did not undergo surgery. We analyzed early and late outcomes of surgical and nonsurgical patients. RESULTS: The operative mortality was 4.8% (6/124), and the incidences of stroke and prolonged hospital stay (>30 days) were 17.7% (22/124) and 20.1% (25/124), respectively. The actuarial survivals at 1, 3, and 5 years were 89.3%, 84.7%, and 79.1%, respectively. Predictors of stroke are preoperative cardiopulmonary resuscitation (odds ratio, 17.5; 95% confidence interval, 3.1-98.9; P = .001) and previous cardiac surgery (odds ratio, 14.0; 95% confidence interval, 1.2-164.7; P = .036). The 30-day or in-hospital mortality of patients who were indicated for surgery but refused surgery was 63.6% (7/11). CONCLUSIONS: Emergency open surgery for type A acute aortic dissection in elderly patients resulted in a low mortality but high incidences of stroke and prolonged hospital stay. Preoperative cardiopulmonary resuscitation and previous cardiac surgery were significant predictors of stroke. Emergency surgery is still the primary option for most elderly patients with acute aortic dissection.

[Mitral valve replacement in dextrocardia and situs inversus].

Cardiac surgery for acquired valvular diseases in patients with dextrocardia is extremely rare. We report a surgical case of mitral valve replacement and tricuspid annuloplasty in a patient with dextrocardia and situs inversus. A 74-year-old man with dextrocardia and situs inversus, who had undergone patch closure of atrial septal defect 25 years before, was referred for surgical treatment of severe mitral and tricuspid valve regurgitation. Preoperative computed tomography( CT) showed dextrocardia, situs inversus, interruption of the inferior vena cava with an azygos vein continuation, and drainage of the hepatic vein into the right atrium. Under redo-median sternotomoy, cardiopulmonary bypass was established by cannulating the ascending aorta, the superior vena cava, the right femoral and the hepatic veins. The surgeon operated from the left side of the operating table, and had an excellent exposure to the mitral and tricuspid valves during the operation. Mitral valve replacement and tricuspid annuloplasty were performed successfully. The postoperative course was uneventful.

Prior cardiac and thoracic aortic surgery as a complication risk factor for abdominal aortic aneurysm repair.

BACKGROUND: Patients with both cardiothoracic lesions and abdominal aortic aneurysm (AAA) are increasing in Japan. The objective of this study was to clarify the effect of 2-staged surgery on complication rates. METHODS AND RESULTS: Three hundred and forty-six patients who underwent elective surgery for infrarenal AAA were entered. History of cardiac and thoracic aortic surgery within 1 year before AAA repair was recorded. A retrospective study regarding perioperative complications was performed. Operative mortality and complication rates were 0.6% and 10.7%, respectively. Seventy patients (20.2%) underwent prior cardiac and thoracic aortic surgery before AAA repair. There was no significant difference in preoperative characteristics between the group with prior cardiac and thoracic aortic surgery and the group without prior surgery. Significant risk factors for postoperative morbidity were: (1) prior cardiac and thoracic aortic surgery (odds ratio [OR] 2.5; 95%CI 1.1-5.1); (2) open aneurysm repair (OAR) (OR 2.7; 95%CI 1.3-5.1); and (3) VSG-CRI score ≥6 (OR 2.9; 95%CI 1.2-6.8). Subanalysis revealed that, although prior cardiac and thoracic aortic surgery was still a risk within patients undergoing OAR, it was not a risk factor for patients undergoing endovascular aneurysm repair (EVAR). CONCLUSIONS: Prior cardiac and thoracic aortic surgery carries high risk for AAA repair. To lower complication rates, we propose to perform EVAR on these patients if they are anatomically suitable.

Outcomes of total arch replacement with stepwise distal anastomosis technique and modified perfusion strategy.

OBJECTIVE: Total arch replacement has been reported to present high morbidity and mortality. We have introduced a stepwise distal anastomosis technique and modified perfusion strategy, including selective antegrade cerebral perfusion, moderate hypothermia, and separate lower-body perfusion, to minimize organ ischemia and secondary morbidities. We report the operative outcomes of total arch replacement with our modified perfusion strategy. METHODS: Between August 2006 and December 2008, 119 patients underwent total arch replacement with the current perfusion strategy. Of these patients, 56 (47%) underwent emergency operation for acute type A aortic dissection (n = 48) or ruptured thoracic aneurysm (n = 8). The mean age of patients was 68 years, and the mean follow-up period was 25 months. We analyzed operative mortality, morbidity, and 4-year survival of this patient group. RESULTS: The mean operation, cardiopulmonary bypass, and circulatory arrest times were 313, 183, and 47 minutes, respectively. Operative mortality was 3.4%. Operative mortality of elective cases was 1.6%. The incidences of permanent neurologic deficit, paraparesis, and renal insufficiency were 5.0%, 1.7%, and 7.6%, respectively. Actuarial 4-year survival was 86.5%. CONCLUSIONS: Total arch replacement with our modified perfusion strategy has demonstrated low operative mortality and morbidity.

Graft selection in elderly patients undergoing coronary artery bypass grafting.

PURPOSE: This study aimed to assess the clinical and angiographic outcomes after coronary artery bypass grafting (CABG) in elderly patients (≥75 years). METHODS: We reviewed the records of 1021 patients who underwent CABG between September 2004 and December 2009. We divided these patients into two groups: ≥75 years (group E, n = 292) versus <75 years (group N, n = 729). We compared operative and postoperative variables and early and 1-year angiographic patency rates of grafts between the groups. RESULTS: The rates of female sex (P < 0.01), unstable angina (P = 0.04), and history of congestive heart failure (P < 0.01) were higher in group E than in group N. More patients in group N had diabetes (P = 0.03) and hyperlipidemia (P < 0.01) than those in group E. Operative mortality (1.0% in group E vs. 0.3% in group N; P = 0.14) and the rate of major complications were not significantly different between the groups. The mean number of anastomoses per patient was similar in the groups. The rate of left internal thoracic artery use was not significantly different between the groups, although the use of other arterial grafts was significantly higher in group N than in group E. There were no significant differences in the early (98.5% vs. 97.2%, P = 0.08) or 1-year (91.6% vs. 89.3%, P = 0.28) patency rates of all grafts in the groups. CONCLUSION: The clinical and angiographic outcomes after CABG in elderly patients were almost identical to those in nonelderly patients.

Mechanisms of recurrent regurgitation after valve repair for prolapsed mitral valve disease.

BACKGROUND: We assessed mitral valve (MV) function using serial echocardiography as an indicator of the durability of MV repair. The aim of this study was to analyze the mechanisms of recurrent regurgitation after MV repair for degenerative disease. METHODS: From 1991 to 2007, 736 patients had valve repair for mitral regurgitation caused by leaflet prolapse: 346 patients had posterior and 390 had anterior leaflet prolapse. The mean age was 54.6±14.6 years, with 495 males. The durability and mechanisms of recurrent regurgitation were evaluated by the findings of echocardiography and reoperation. Follow-up and late echocardiography averaged 5.7±3.9 and 5.1±3.6 years, respectively. RESULTS: Survival was 91.9%±1.5% at 10 years. Freedom from reoperation and moderate or severe regurgitation at 10 years were 91.2%±1.7% and 84.5%±2.1%, respectively. Reoperations were performed for recurrent regurgitation in 29 patients, hemolysis in 5, and endocarditis in 1. Based on the findings of reoperation, the mechanisms of repair failure were procedure related in 9 (25.7%), valve related in 25 (71.4%), and unknown in 1. Late echocardiography revealed none to trivial regurgitation in 511 patients, mild in 153, moderate in 26, and severe in 40. Anterior leaflet prolapse, preoperative atrial fibrillation, and no use of annuloplasty ring were independent predictors of recurrent regurgitation. The main causes of moderate or severe regurgitation were leaflet thickening in 34 patients, leaflet prolapse in 20, dehiscence in 10, and unknown in 2. CONCLUSIONS: The main mechanism of recurrent regurgitation after MV repair is progressive degeneration that is characterized by leaflet thickening and prolapse, especially in patients with anterior leaflet prolapse.

Early tracheal extubation after on-pump coronary artery bypass grafting.

OBJECTIVE: A fast-track recovery in cardiac surgery yields many benefits, and early tracheal extubation is important as the first step. The purpose of this study is to evaluate the status of early tracheal extubation after on-pump coronary artery bypass grafting (CABG) and to find key factors for successful early tracheal extubation. METHODS: From September 1996 to February 2005, isolated on-pump CABG was performed on 485 patients, and an early tracheal extubation protocol was employed on all. It was defined as tracheal extubation within 6 hr of arrival in the intensive care unit (ICU). RESULTS: An early tracheal extubation was successful on 450 patients (92.5%). Reintubation was necessary in 5 (1.1%) because of a resternotomy for bleeding in 3 and ventricular arrhythmia in 2. Mechanical ventilation exceeding 24 hours was required in 7 patients (1.4%) because of heart failure in 4 and respiratory failure in 3. Significant factors of successful early tracheal extubation were the European System for Cardiac Operative Risk Evaluation (P <0.05), the number of diseased arteries (P <0.01), ejection fraction (P <0.05), operation time (P <0.01), blood transfusion in ICU (P <0.05), and drainage in the first 12 hr (P <0.05). CONCLUSIONS: Early tracheal extubation can be successfully performed in most patients receiving on-pump CABG. The management of higher-risk patients and efforts to reduce operation time and blood loss are keys to success for early tracheal extubation.

Long-term outcome of mitral valve repair for infective endocarditis.

BACKGROUND: In patients with mitral endocarditis, reconstruction of the damaged mitral valve (MV) is still challenging, and its durability remains unknown. We evaluated the long-term outcomes of MV repair for mitral regurgitation (MR) in patients with infective endocarditis. METHODS: From 1991 to 2006, 633 patients had MV repair for MR caused by leaflet prolapse: 78 had endocarditis (active in 14, healed in 64) and 555 had degenerative disease. Durability was assessed by reoperation and recurrent MR. RESULTS: The overall hospital mortality rate was 1.0% (endocarditis 0% vs degenerative 1.1%; p = 0.99). The 10-year survival and freedom from reoperation were 91.1 +/- 1.6% and 92.2 +/- 1.7%, respectively, with no differences between endocarditis and degenerative disease. Older age, New York Heart Association class III or IV, impaired ventricular function, and no use of annuloplasty were independent predictors of all-cause death. Freedom from moderate or severe MR was 99.8 +/- 0.2% at 2 weeks, 91.9 +/- 1.5% at 5 years, and 83.3 +/- 2.3% at 10 years, for all patients and did not differ between groups at 10 years (p = 0.388). Anterior leaflet prolapse, preoperative atrial fibrillation, and no annuloplasty were independent predictors of recurrent MR. In endocarditis patients, recurrent MR was mainly caused by leaflet thickening and calcification, but not by recurrence of endocarditis. CONCLUSIONS: MV repair for endocarditis is associated with low operative mortality and morbidity, and its long-term durability is comparable with that of repair for degenerative disease. This study suggests that a degenerative process causes late failure after MV repair for endocarditis.

Intermediate-term patency of saphenous vein graft with a clampless hand-sewn proximal anastomosis device after off-pump coronary bypass grafting.

BACKGROUND: To avoid complications related to aortic manipulation, devices were developed to perform clampless anastomosis. However, there are few studies concerning the late patency of the graft. The aims of this study were to investigate the patency rate of saphenous vein (SV) graft after off-pump coronary artery bypass grafting (OPCAB) and to evaluate the influence of a clampless hand-sewn proximal anastomosis on late graft patency. METHODS: Patients (n = 232) were enrolled who underwent OPCAB with SV grafts from 2004 to 2007 and had follow-up angiography. For proximal anastomoses, a clampless device was used in 73 (group A; HEARTSTRING [Guidant Corporation, Santa Clara, CA] in 54, Enclose II [Novare Surgical Systems, Inc, Cupertino, CA] in 19), and partial clamping was used in 159 (group B). The proximal anastomosis procedure was modified according to the results of epiaortic ultrasonography. Coronary angiography was performed early (11.8 +/- 10.4 days) and one-year postoperatively (n = 180, 371.5 +/- 102.6 days). RESULTS: There were no significant differences in patient characteristics between the two groups except for a higher reoperation rate in group A. The overall SV patency rate at the early and one-year postoperative angiography was 95.7% and 83.0%, respectively. The patency rates were similar between the two groups (early: 97.3% vs 98.1%, p = 0.729; 1 year: 87.0% vs 81.3%, p = 0.316). There was also no significant difference in the target vessel revascularization rate during follow-up (6.8% vs 10.1%, p = 0.623). CONCLUSIONS: Intermediate-term angiographic follow-up demonstrate an acceptable SV patency rate after OPCAB. The SV patency rate with a clampless device for proximal anastomosis is comparable with that with partial clamping during the first postoperative year.

Impact of proximal anastomosis procedures on stroke in off-pump coronary artery bypass grafting.

BACKGROUND: There are many options for proximal anastomosis during off-pump coronary artery bypass grafting (CABG), but the efficacies of these procedures have not been well clarified. Therefore, we examined the clinical impact of our strategy to modify the proximal anastomosis procedure for aortic atherosclerosis. METHODS: We retrospectively reviewed 535 consecutive patients undergoing off-pump CABG between 2004 and 2007. The patients were divided into three groups depending upon the type of proximal anastomosis procedure: 241 patients with normal or mild atherosclerosis underwent partial clamping (clamp group), 81 patients with moderate atherosclerosis underwent the procedure with Heartstring (Guidant Corporation, Santa Clara, CA, USA), 28 patients underwent with Enclose II (Novare Surgical Systems, Inc., Cupertino, CA, USA) (device group), and 185 patients underwent the procedure without clamping, including six with severe atherosclerosis (no-touch group). RESULTS: There were seven in-hospital mortalities (1.3%) and five strokes (0.9%). There was no difference in the mortality rate (clamp, 1.2%; device, 1.8%; no-touch, 1.1%; p = 0.42) or stroke rate (clamp, 0.8%; device, 2.8%; no-touch, 0.5%; p = 0.09) among the three groups. Graft patency was similar regardless of the method (clamp, 94.7%; Heartstring, 96.7%; Enclosed II, 96.0%; p = 0.80). CONCLUSIONS: Our strategy to modify the proximal anastomosis procedure resulted in a low stroke rate. Aortic clamping could be performed safely in patients with normal or mild atherosclerotic aorta. In patients with moderate atherosclerosis, the result of an anastomotic device may need a further investigation.

Emergent mitral valvuloplasty with an autologous pericardial patch in an octogenarian with active infective endocarditis.

An 83-year-old woman with suppurative spondylitis was referred to our hospital due to active infective endocarditis with an expanding mobile vegetation and a high echoic mass on the posterior mitral leaflet. During the operation, the high echoic mass was found to be a chronically organized abscess, which was located at the base of the vegetation on the posterior leaflet and extended toward the annulus. The patient underwent a successfully emergent resection of the vegetation and mass, and valvuloplasty using an autologous pericardial patch with an excellent outcome.

Characteristic changes in cerebral perfusion during on-pump and off-pump coronary artery surgery.

OBJECTIVE: We investigated the cerebral perfusion status during on-pump or off-pump coronary artery bypass grafting (CABG). METHODS: We monitored somatosensory evoked potential (SEP) and regional cerebral oxygen saturation (rSO2) as parameters of cerebral perfusion in an on-pump group (n=10) and an off-pump group (n=16). The percent changes from control values were calculated before, during, and after aortic clamping, and after weaning from cardiopulmonary bypass, in the on-pump group. In the off-pump group, these were calculated before, during, and after heart displacement for distal anastomosis. RESULTS: In the on-pump group, the amplitudes of the SEP were significantly enhanced during and after aortic cross-clamping and were associated with a significant decrease in rSO2. Latency was prolonged immediately after aortic cross-clamping, but was shortened afterwards. There was little change in these parameters throughout the operation, in the off-pump group. CONCLUSIONS: Cerebral perfusion remains stable during off-pump CABG. The etiology of a simultaneous increase in SEP amplitude and decrease in rSO2 during the rewarming period in the on-pump group requires further investigation.