[Primary Cardiac Undifferentiated Pleomorphic Sarcoma in the Left Atrium:Report of a Case].

A rare case of primary cardiac undifferentiated pleomorphic sarcoma (UPS) is reported. A 77-yearold female was admitted to the authors' hospital with complaints of palpitation and dyspnea on effort. Echocardiography revealed a mobile tumor arising from the atrial septum of the left atrium. The tumor obstructed the mitral valve and the patient experienced acute heart failure. Emergent open-heart surgery was performed to resect the tumor. Although she was discharged from hospital on postoperative day 14 in a satisfactory condition, local recurrence in the left atrium was observed 16 months after surgery. Repeated tumor resection was performed, and histological examination confirmed UPS. The patient did not agree to undergo chemotherapy or radiation therapy and died of local recurrence 27 months after the first surgery.

Artificial endocrine pancreas with a closed-loop system effectively suppresses the accelerated hyperglycemic status after reperfusion during aortic surgery.

OBJECTIVES: To control intraoperative hyperglycemia in patients who underwent aortic surgery using STG-55® artificial endocrine pancreas and clarify the effectiveness of this device. METHODS: Blood glucose control using the STG-55® was performed in 18 patients (15 men and 3 women; age, 66 ± 10 years) who required hypothermic circulatory arrest (STG-55® group). Seventeen patients (10 men and 7 women; age, 71 ± 8 years) whose blood glucose was controlled using the conventional method were included in the control group. Glucose concentration was controlled with the aim of maintaining it at 150 mg/dl. RESULTS: In both groups, the blood glucose concentrations did not significantly change during the interruption of systemic perfusion; however, a sharp increase was noted immediately after reperfusion. Although the hyperglycemic status persisted after reperfusion in the control group, it was effectively suppressed in the STG-55® group (STG® vs. control group at 50 min after reperfusion: 180 ± 35 vs. 212 ± 47 mg/dl, p = 0.026) and blood glucose concentration reached the target value of 150 mg/dl at 100 min after reperfusion (STG® vs. control group: 153 ± 29 vs. 215 ± 43 mg/dl, p = 0.0008). The total administered insulin dose was 175 ± 81 U and 5 ± 3 U in the STG® and control groups, respectively (p < 0.0001). CONCLUSIONS: To treat the accelerated hyperglycemic status in aortic surgery requiring circulatory arrest, strict glycemic control using an artificial endocrine pancreas might be beneficial.

[Coronary Artery Perforation during Excimer Laser Coronary Angioplasty;Report of a Case].

Coronary perforation during excimer laser coronary angioplasty( ELCA) is a rare but life threatening complication. A 55-year-old man was admitted to our hospital for management of acute coronary syndrome. ELCA was attempted for the left anterior descending coronary artery (LAD);however, coronary perforation of LAD occurred during the procedure. The patient was transferred to the operation theater and emergency surgical repair was performed. LAD and the diagonal branch were ligated, an aorto-coronary bypass grafting for the distal LAD and the diagonal branch using the saphenous veins. His postoperative course was uneventful, and the patient was discharged on the 23rd postoperative day. In case of coronary perforation complicated by ELCA, immediate surgical repair is essential.

[Pseudo-false Aneurysm of the Left Ventricle after Acute Myocardial Infarction;Report of a Case].

A 77-year-old man was admitted to a regional hospital to undergo investigation of abnormal electrocardiographic findings. Coronary angiography revealed 99% stenosis of the right coronary artery(RCA) segment 3 and 75% stenosis of the left anterior descending artery (LAD)segment 7. Left ventriculography revealed an aneurysm at the inferior wall of the left ventricle. On computed tomography and echocardiography, a saccular aneurysm at the inferior wall, 15 mm in diameter, was observed. Under the suspicion of a ventricular false aneurysm resulting from myocardial infarction, aneurysmectomy, patch closure of the aneurysmal orifice and coronary artery bypass grafting to the LAD and RCA were performed. No pericardial adhesion to the ventricular aneurysm was observed. His postoperative course was uneventful, and he was discharged from the hospital on the 28th postoperative day in good condition. The pathological examination revealed residual cardiomyocytes with the aneurysmal wall.

[Coronary Artery Perforation Secondary to Primary Percutaneous Coronary Intervention;Report of a Case].

Stent perforation of a coronary artery during percutaneous coronary intervention (PCI) is a rare but life-threatening complication. A 70-year-old man was admitted to our hospital for management of acute coronary syndrome. PCI was attempted for the left circumflex artery(LCX);however, catheterization was complicated by perforation of the LCX by the stent. He developed cardiac tamponade and was resuscitated using percutaneous cardiopulmonary support. Emergency surgery( ligation of the LCX and aorto-coronary bypass grafting for the distal LCX) was performed. His postoperative course was uneventful, and the patient was discharged on the 20th postoperative day. Collaboration between cardiologists and surgeons is essential to salvage such a critical patient.

Left ventricular blood cyst in an adult case.

We present a 57-year-old man with a 1.5-cm-diameter blood cyst in the left ventricle, which was incidentally detected by conventional diagnostic echocardiography before colon surgery. The cyst originated from the papillary muscle, and the pathological findings were compatible with a cardiac blood cyst.

[Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

Unique nonstructural dysfunction of the omnicarbon valve: case report.

BACKGROUND: Pannus formation may disturb the leaflet movement of the prosthetic valve. CASE PRESENTATION: A 61-year-old woman presented with exertional dyspnea. She had undergone mitral valve replacement with a bioprosthetic valve 31 years ago, which was replaced with a tilting disc valve 22 years ago. The present laboratory findings revealed hemolytic anemia. Echocardiography showed an increased mean pressure gradient through the mitral valve and moderate to severe regurgitation around the minor orifice of the tilting disc valve. She therefore underwent a third operation. Pannus formation was found on the prosthetic valve ring, but it did not obliterate the prosthetic valve orifice. After removing the valve, the posterior wall of the left ventricle was seen to be associated with thickened endocardium. A bileaflet valve was implanted. Postoperative echocardiography showed that the implanted valve functioned well. CONCLUSIONS: Nonstructural dysfunction of the mechanical heart valve might occur long after operation. These changes are particularly observed with a tilting disc valve.

[Surgical Treatment of Prosthetic Valve Endocarditis].

Between 2003 and 2014, at Jichi Medical University Hospital, 11 patients with prosthetic valve endocarditis (PVE) underwent re-operation. There was 1 in-hospital death and 2 late deaths. The cause of death was cirrhosis, heart failure and sepsis, respectively. Emergency surgery, previous double valve replacement (DVR) and Staphylococcus infection were common risk factors for all 3 cases. Two cases of patients that survived who underwent mitral valve replacement (MVR) and DVR for PVE after DVR were treated with multiple antibiotic courses for bacteremia associated with hemodialysis and colon cancer. One patient who underwent DVR after mitral valve plasty which was complicated with cerebral hemorrhage, had survived and was discharged. Of the aortic PVE patients, 2 cases of aortic valve replacement (AVR) using a mechanical valve, 1 case of aortic root replacement (ARR) using a mechanical valve, and 1 ARR using the homograft, were considered cured and never relapsed. A patient with aortic PVE, who underwent AVR after cesarean section for heart failure in birth period, has received ARR twice with the mechanical valve for recurrent pseudo-aneurysm of the left ventricular outflow tract. Since hemodialysis and colon cancer is a risk factor for recurrent PVE, it is necessary to consider the long-term administration of antibiotics after surgery.

Fifteen-year experience with the Bicarbon heart valve prosthesis in a single center.

BACKGROUND: The purpose of this study was to evaluate retrospectively the clinical performance of the Bicarbon valve (Sorin Biomedica Cardio, Saluggia, Italy) implanted at our center in Japan. METHODS: Between January 1997 and December 2011, 415 patients in our institution were implanted with the Bicarbon valve. Nine of these recipients were excluded from the study because they had already undergone valve implantation and received a Bicarbon valve in a different position. The remaining patients were analyzed for evaluation of the postoperative clinical outcomes. Of the 406 patients (mean age 60.2 ± 11.7 years), 179 underwent aortic valve replacement (AVR), 149 mitral valve replacement (MVR), and 78 both aortic and mitral valve replacement (DVR). RESULTS: There were 10 early deaths (2.5 %: 4 in the AVR group and 6 in the MVR group). Three hundred eighty-nine patients were followed up (95.8 % completeness of follow-up) with a mean follow-up of 6.6 ± 4.2 years overall (AVR 6.8 ± 4.2, MVR, 6.7 ± 4.4, and DVR 5.7 ± 3.4 years) and a cumulative follow-up of 2661 patient-years (1214, 1001, and 446 patient-years for AVR, MVR, and DVR, respectively). Ninety-nine patients died (3.7 % per patient-year: 22 valve-related and 77 valve-unrelated deaths). Survival at 10 years was 74.1 ± 4.0 % in the AVR group, 73.7 ± 4.2 % in the MVR group, and 61.0 ± 7.9 % in the DVR group. The linearized incidence of thromboembolic complications, bleeding complications, prosthetic valve endocarditis, paravalvular leaks, and sudden death in all patients was 0.5 %, 0.5 %, 0.2 %, 0.2 %, and 0.4 % per patient-year, respectively. The incidence of valve-related complications and reoperation was 1.6 % and 0.4 %, respectively. No other valve-related complications were observed. CONCLUSIONS: The Bicarbon prosthetic heart valve has shown excellent clinical results and is associated with a low incidence of valve-related complications.

[Pannus Formation Six-years after Aortic and Mitral Valve Replacement with Tissue Valves;Report of a Case].

A 77-year-old man presented with exertional dyspnea. He had undergone aortic and mitral valve replacement with tissue valves 6-years earlier. The patient's hemoglobin level was 9.8 g/dl and serum aspartate aminotransferase (70 mU/ml) and lactate dehydrogenase (1,112 mU/ml) were elevated. Echocardiography revealed stenosis of the prosthetic valve in the aortic position with peak flow velocity of 3.8 m/second and massive mitral regurgitation. The patient underwent repeat valve replacement. Pannus formation around both implanted valves was observed. The aortic valve orifice was narrowed by the pannus, and one cusp of the prosthesis in the mitral position was fixed and caused the regurgitation, but they were free from cusp laceration or calcification. The patient's postoperative course was uneventful, and he continues to do well 14 months after surgery.

[Left Ventricular Rupture during Both Mitral and Aortic Valve Replacements].

A 73-year-old woman on hemodialysis was transferred to our hospital for surgical treatment of heart valve disease. She required both mitral and aortic valve replacement with mechanical valves, associated with tricuspid annuloplasty. After aortic de-clamping, a massive hemorrhage from the posterior atrioventricular groove was observed. Under repeated cardiac arrest, the left atrium was reopened, the implanted mitral prosthetic valve was removed and a type I left ventricular rupture (Treasure classification) was diagnosed. The lesion was directly repaired with mattress stitches and running sutures, using reinforcement materials such as a glutaraldehyde-treated bovine pericardium. To avoid mechanical stress by the prosthetic valve on the repaired site, a mechanical valve was implanted using a translocation method. The patient suffered from aspiration pneumonia and disuse atrophy for 3 months. However, she was doing well at 1 year post-operation.

[Maze procedure in a case of dextrocardia with atrial septal defect and persistent left superior vena cava].

A 52-year-old man was diagnosed with dextrocardia at the age of 1 year and was asymptomatic until 1 year before admission. He was transferred to our hospital for management of atrial fibrillation. A transthoracic echocardiogram showed dextrocardia with atrial septal defect;moderate tricuspid valve regurgitation; and a large, persistent left superior vena cava. A cardiac catheterization study revealed that pulmonary flow/systemic flow (Qp/Qs) was 3.6 and that pulmonary vascular resistance was 2.5 Wood U·m². Intracardiac repair with tricuspid annuloplasty and a maze procedure was scheduled. When establishing cardiopulmonary bypass, venous drainage was initially obtained from the inferior vena cava and the left superior vena cava, and the small superior vena cava was then directly cannulated after opening the right atrium. The patient's postoperative course was uneventful, and serial electrocardiograms have demonstrated maintenance of normal sinus rhythm for 3.5 years after the operation.

Side-to-side anastomosis using 4 interrupted sutures in small coronary arteries.

Side-to-side anastomosis in sequential bypass grafting of coronary arteries 1.0 mm in diameter or smaller, requires delicate surgical techniques with a high degree of technical difficulty. However, using only 4 interrupted sutures, we have performed side-to-side anastomosis in sequential grafting without difficulty in a short operative duration. We applied this technique in 58 distal anastomosis procedures, achieving an early angiographic graft patency rate of 100%.

[Successful repair of isolated extracardiac unruptured sinus of Valsalva aneurysm; report of a case].

We report a case of isolated, unruptured extracardiac aneurysm of the right coronary sinus of Valsalva. The aneurysm was detected incidentally in a 75-years-old woman during the treatment of angina pectoris. A 30×35 mm sized aneurysm was located in the right sinus of Valsalva with extracardiac protrusion. It was repaired by obliterating its orifice with an autologous pericardial patch reinforced by a polytetrafluoroethylene (PTFE) patch. Early surgical repair should be a treatment of choice for this entity to prevent catastrophic event.

A case of ascending aortic pseudoaneurysm in a patient with aortic replacement.

A 59-year-old man with a history of ascending aorta replacement for an aortic dissection using gelatin-resorcin-formalin glue at age of 50 years presented with paroxysmal nocturnal dyspnea. An echocardiogram showed severe aortic regurgitation associated with aortic root enlargement. Chest computed tomography showed that the ascending aorta was dilated and a pseudoaneurysm was observed around the implanted prosthetic graft. Upon opening the ascending aorta, we found that the posterior wall of the proximal anastomotic portion of the implanted graft was ruptured. After replacement of the aortic root with a composite graft and reconstruction of the orifices of the right and left coronary arteries, total arch replacement by the separated graft technique was performed. The postoperative course was uneventful.

[Mitral valve repair for active infectious endocarditis].

Between December 2005 and November 2011, 11 patients with mitral valve regurgitation (MVR) resulting from native valve endocarditis underwent mitral valve plasty (MVP). These patients were aged 44.4 ± 11.3 years. The mean follow-up period of the patients was 3.1 ± 0.63 years. Five patients were men. Emergency or urgent surgery was required in 5 patients. Three patients were categorized as New York Heart Association( NYHA) functional class IV. Infection of the mitral valve, occurred in the anterior leaflet in 3 patients, the posterior leaflet in 5 patients, and the anterior-posterior leaflet in 3 patients. Nine patients had a resection suture technique. One patient had chordae replacement with expanded polytetrafluoroethylene (ePTFE), and 1 patient had replacement using the pericardium. All patients received ring annuloplasty with a partial flexible ring. After surgery, all patients were categorized as NYHA functional class I. There were no valve associated complications, no hospital deaths, no late deaths, and no reoperations. We conclude that MVP is an effective treatment for active infective endocarditis( AIE) with mitral regurgitation.

[Reoperative off-pump coronary revascularization via left thoracotomy using the PAS-Port system to the descending thoracic aorta: report of a case].

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.

[Aortic root rupture during an operation in a patient with acute aortic dissection].

A 73-year-old woman with acute aortic dissection (DeBakey type II) and cardiac tamponade was transferred to our emergency unit. She had a temporary blackout during transfer. An emergency operation was performed. We started core cooling with the superior vena cava, inferior vena cava, and transapical aortic cannulation. When the bladder temperature was 30.5 degrees C, esophageal temperature was 28.7 degrees C, and rectal temperature was 30.5 degrees C, the aortic root suddenly ruptured. We changed the arterial cannulation sites from the apex to the dissecting ascending aorta, and the ascending aorta was cross-clamped. However, the patient's pupils became dilated. Therefore, we started selective cerebral perfusion to avoid prolonged cerebral malperfusion. This procedure took approximately 30 minutes, from the aortic root rupture to selective perfusion. We performed both aortic root and ascending aortic replacement. After the operation, the patient had no neurological or other organ complications and she was discharged 11 days after surgery.