Comprehensive Pain Control Strategy in Minimally Invasive Mitral Valve Repair.

PURPOSE: The effect of our comprehensive strategy to reduce pain after minimally invasive mitral valve repair through a right mini-thoracotomy was assessed retrospectively. METHODS: Our comprehensive strategy constituted the following: planned rib cutting to avoid rib injury, sufficient intercostal muscle division to mobilize the cut rib, limiting the number of intercostal ports, avoiding nerve entrapment, continuous extra-pleural intercostal nerve block, and regular use of oral non-steroidal anti-inflammatory drugs. We compared patients treated with this comprehensive strategy (Group S, n = 13) and patients before this strategy was implemented (Group C, n = 13). We used a numerical rating scale (NRS) as a pain scale during the first 3 days postoperatively. RESULTS: The average NRS was significantly lower in Group S (0.82 ± 0.49) than in Group C (2.40 ± 1.46) (P <0.01). The maximum NRS was also significantly lower in Group S (3.23 ± 1.17) than in Group C (5.69 ± 2.43) (P <0.01). The number of patients using additional single-dose analgesic were significantly less in Group S (23.1%) than in Group C (84.6%) (P <0.01). CONCLUSION: Our comprehensive pain control strategy effectively reduced postoperative pain in minimally invasive mitral valve repair.

Utility of Ultrasonographic Assessment of Distal Femoral Arterial Flow during Minimally Invasive Valve Surgery.

PURPOSE: To evaluate the utility of ultrasonographic assessment of blood flow to the lower limb below the cannulation site in minimally invasive cardiac surgery (MICS). METHODS: Twenty-two patients who underwent ultrasonographic assessment in MICS were reviewed retrospectively. In all patients, the right femoral artery was used for arterial cannulation. Ultrasonographic assessment was performed using a 15-MHz ultrasonography small probe, and regional oxygen saturation was monitored by near-infrared spectroscopy (NIRS). RESULTS: The mean flow velocity at the distal side of the cannulation site was 46.2 ± 25.4 cm/s. In six patients, a >40% decreased from baseline regional oxygen saturation was observed. In five of the six patients, the flow velocity was very slow, and spontaneous echo contrast was also observed in three cases. Their regional oxygen saturation was improved rapidly after distal leg perfusion. In the remaining case, the flow velocity was not decreased. In another one case, the stenosis at the cannulation site was detected after decannulation and repaired immediately. No limb ischemic complications were observed in this series. CONCLUSION: Ultrasonographic assessment combined with the NIRS monitoring is useful to prevent lower limb ischemic complications after femoral arterial cannulation in MICS.

[Metastasis of Clear Cell Renal Cell Carcinoma to the Left Ventricle].

Cardiac metastasis from renal cell carcinoma (RCC) is relatively rare. It generally initiates from the right atrium with or without involvement of the inferior vena cava (IVC). Here, we report a case of metastasis of isolated clear cell RCC to the left ventricular( LV) papillary muscle. An 84-year-old male who had undergone renal resection due to RCC 19 years before, presented to our hospital with suspected LV tumor by echocardiography. The tumor was located near the posterior papillary muscle, with a size of 15×12 mm. The patient underwent resection of the LV tumor. Pathologically, the tumor was diagnosed as clear cell RCC. The postoperative course was stable, and he did not require any chemotherapy. Although there is no definite evidence of the mechanisms of metastasis, the tumor was supposed to metastasize lymphogeneously.

Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery.

An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered.

Management of infectious endocarditis with mycotic aneurysm evaluated by brain magnetic resonance imaging.

OBJECTIVES: Cerebral complications of infective endocarditis (IE) [particularly, mycotic aneurysm, visualized as a hypointense spot on T2*-weighted brain magnetic resonance imaging (MRI)] are associated with a high incidence of postoperative cerebral or subarachnoid hemorrhage. We have adopted a policy of performing elective open heart surgery after performing a MRI enhanced by gadolinium in such patients whenever possible after improvement in inflammatory findings around a cerebral aneurysm. METHODS: Fifty-six patients (35 men and 21 women, mean age 56 years) diagnosed with active-phase IE between January 2000 and December 2010 were analysed retrospectively. RESULTS: Six patients who had not undergone MRI were excluded. The remaining patients were classified into four groups according to preoperative brain MRI findings-Group A (n = 13): cerebral haemorrhage, cerebral infarction, abscess and encephalitis; Group B (n = 7): simple or multiple black dots ( = hypointensive spots) with cerebral haemorrhage or cerebral infarction; Group C (n = 15): simple or multiple black dots alone; Group D (n = 15): no abnormal MRI findings. None of the 12 patients who successfully underwent elective surgery in Groups B and C developed postoperative cerebral complications. CONCLUSIONS: Brain MRI is an important tool for the detection of asymptomatic intracranial abnormalities associated with IE and evaluation of the preoperative bleeding risk of patients. Patients with contrast enhancement around black dots are at high risk for bleeding, and performing open heart surgery in such patients whenever possible after the improvement of inflammatory findings reduces the potential risk of cerebral haemorrhage.

Body surface two-dimensional spectral map of atrial fibrillation using vector-projected 187 channel electrocardiography.

Atrial cycle length during atrial fibrillation and flutter waves may be correlated with atrial refractoriness and organization. The nature of the frequency by spectral analysis may reflect a profile of atrial cycle length. In this study, we developed a novel body surface 2-dimensional spectral map during fibrillation using vector-projected 187 channel ECG (187ch VP-ECG).The study consisted of 28 patients (24 with atrial fibrillation (AFIB) and 4 atrial flutter (AFL) with valvular heart disease). We performed spectral analysis by maximum entropy modeling (MEM) in 4 second nonaveraged 187ch electrical current waves by 187ch VP-ECG. Body surface spectral features were displayed according to the frequency and power magnitude components. We verified the accuracy of the spectral features by a 64ch magnetocardiography (MCG). The average dominant frequency in AFL by 187ch VP-ECG was lower than those in AFIB (4.6 ± 0.9 Hz in AFL, 7.2 ± 0.9 Hz in AFIB, P < 0.01). Comparison of average dominant frequency between 187ch VP-ECG and 64 ch MCG demonstrated good agreement (y = 0.86x+0.84, r(2) = 0.89, P < 0.0001). Body surface 2-dimensional spectral features demonstrated homogenous spectrum patterns in AFL, and in-homogenous spectrum patterns in AFIB.In conclusion, novel body surface spectral mapping using 187ch VP-ECG may represent a 2-dimensional spectral feature that may be related to atrial refractoriness and organization.

Bentall operation with saphenous vein graft for a Takayasu's aortitis patient.

Takayasu's aortitis patients present a variety of symptoms, including angina pectoris, aortic valve regurgitation, and aortic branch stenosis. The case described in this paper primarily presented with angina pectoris. Close investigation revealed a left coronary artery ostium lesion, an aortic root aneurysm, and a mild aortic regurgitation. The patient underwent a modified Bentall operation with saphenous vein graft (SVG) replacement of the left main trunk. The postoperative course was uneventful, and the patient received oral steroid therapy. SVG is a useful option in treating aortic root aneurysm with an ostium lesion.

[Evaluation of a new method of pericardial drainage after cardiac surgery].

Recently pericardial drainage after cardiac surgery has been done using silicon tubes of small diameter. For more effective drainage, we set one of the drainage tubes circularly, coursing behind the left ventricle, through the transverse sinus, and ending at the right side of the atrium (circular pericardial drainage). As compared to conventional drainage using 28 Fr chloroethilene tubes, drainage time was shorter and no late tamponade had occurred. Circular pericardial drainage may be useful.

Regression of a thrombosed persistent sciatic artery aneurysm.

A 79-year-old woman who had a previous history of sudden onset of pain and coldness of her right leg was referred to our hospital. There were no palpable right popliteal and pedal pulses with the ankle-brachial pressure index being 0.63. Computed tomography showed a 2.6-cm diameter right buttock mass which had a continuation from the right internal iliac artery that entered the posterior thigh and continued to the popliteal artery. It was diagnosed as thrombosed right persistent sciatic artery (PSA) aneurysm. She was treated medically with intravenous and oral antiplatelets, and was left with no right leg symptoms. Follow-up CT obtained after 3 years from onset demonstrated that the diameter of the PSA aneurysm diminished from 2.6 to 1.2 cm. It is suggested that a patient who had the occluded complete type PSA aneurysm with no critical leg ischemia, local compression, or rupture can be observed without surgery. However, careful follow-up of the patient is essential.

Aortic root reimplantation using a Valsalva graft for postoperative pseudoaneurysm after acute aortic dissection.

We report a reoperative case in which a Valsalva graft was utilized on a 64-year-old woman who had previously undergone emergency repair of a DeBakey type I acute aortic dissection. On follow-up computed tomography (CT), she was found to have pseudoaneurysms of both proximal and distal anastomoses. We performed valve-sparing aortic root replacement (VSRR) with the reimplantation technique and total arch replacement, since we felt that a graft with pseudosinuses helps to prevent torsion of the coronary arteries. The postoperative course was uneventful, and postoperative echocardiography revealed no significant aortic valve regurgitation. The pathology results raised the hypothesis that pseudoaneurysm formation might have been related to the use of gelatin-resorcinol-formaldehyde (GRF) glue at the time of the initial intervention.