[Redo Mitral Valve Replacement for Prosthetic Valve Endocarditis in a Patient with End Stage Colon Cancer:Report of a Case].

Prosthetic valve endocarditis (PVE) is rare but devastating. A 69-year old man admitted for active endocarditis caused by Streptococcus pasteurianus. Antibiotic therapy was started, but the patient developed bowel obstruction owing to cancer with multiple liver metastases, and underwent transverse colectomy. Following colectomy, antibiotic agent was given continued for 4 weeks after and mitral valve replacement( MVR) using a bioprosthesis was performed. Oral antibiotic therapy was continued for six months after MVR to avoid infection recurrence. One year after MVR, the size of multiple liver metastases increased despite oral anticancer drugs administration. A totally implantable central venous access port( CV port) was placed and intravenous chemotherapy was started for progressive metastatic colorectal cancer. But the CV port was removed due to device infection caused by multiple drug resistant Staphyrococcus lugdunensis one month later, but the patient developed prosthetic valve endocarditits( PVE) due to the same bacterium, that caused valve stenosis. Redo MVR was indicated because of progressive dyspnea and uncontrollable fever. The patient was discharged one month after redo MVR, but suffered carcinomatous peritonitis, and eventually died eight months post-discharge. Chemotherapy needs caution because of potential risk of PVE in patients with prosthetic valves, especially for those with a history of infectious endocarditis.

[Anomalous Origin of Right Coronary Artery with Intramural Course, Aortic Valve Stenosis and Coronary Artery Stenosis:Report of a Case].

Anomalous origin of the coronary artery is a rare congenital malformation that can cause myocardial ischemia and arrhythmia in patients with or without atherosclerotic lesions. We present a case of aortic stenosis (AS) and coronary artery stenosis complicated by anomalous origin of the right coronary artery (RCA) from the aortic valve sinus and its intramural course. The patient was a 66-year-old woman who was diagnosed with AS 4 years prior, and scheduled for surgery owing to gradual progression of stenosis. Preoperative coronary angiography revealed an abnormal origin of the RCA, and during the surgery, the RCA was found located within the aortic wall close to the aortotomy. Thus, bypass surgery was performed using a great saphenous vein, to prevent ischemia of the RCA territory. The patient had good intraoperative and postoperative course, and a coronary computed tomography scan clearly showed the reconstructed RCA.

Changes in Internal Thoracic Artery Blood Flow According to the Degree of Stenosis of the Anterior Descending Branch of the Left Coronary Artery.

PURPOSE: Computational fluid dynamics has enabled the evaluation of coronary flow reserve. The purpose of this study was to clarify the hemodynamic variation and reserve potential of the left internal thoracic artery (LITA). METHODS: Four patients were selected on the basis of various native coronary stenosis patterns and graft design. The wall shear stress and oscillatory shear index were measured, and one patient was selected. Next, we created three hypothetical lesions with 75%, 90%, and 99% stenosis in front of the graft anastomosis, and compared the changes in LITA blood flow and coronary flow distribution. RESULTS: In the 75% to 90% stenosis model, blood flow was significantly higher in the native coronary flow proximal to the coronary artery bypass anastomosis regardless of time phase. In the 99% stenosis model, blood flow from the LITA was significantly dominant compared to native coronary flow at the proximal site of anastomosis. The range of LITA flow variability was the largest at 99% stenosis, with a difference of 70 ml/min. CONCLUSION: The 99% stenosis model showed the highest LITA flow. The range of LITA flow variability is large, suggesting that it may vary according to the rate of native coronary stenosis.

Triangular resection versus folding repair for simple posterior mitral leaflet lesions: case-control study.

BACKGROUND: A triangular resection (TR)/suture of the posterior leaflet lesion is the most common technique in mitral valve repair procedures. However, posterior leaflet motion is restricted after surgical resection in echocardiogram analyses. Although several reports have compared the resection/suture technique and the artificial chorda technique, few reports have compared TR with folding repair (FR). We compared the effectiveness and short-term impact of the TR and non-resection-based FR procedures on patients undergoing mitral valve repair. METHODS: Mitral valve repair was conducted on 36 patients with moderate to severe mitral regurgitation (MR) through either TR (n=18) or FR (n=18). Echocardiographic data were collected pre- and post-operatively. Routine echocardiographic follow-ups were performed for each patient. Data were analyzed using t-test, Mann-Whitney U-test, chi-squared analysis, or Fisher's exact test. P values <0.05 were considered significant. RESULTS: Operative time and length of stay within the intensive care unit and hospital did not significantly differ between the two techniques. Post-operative echocardiographic results showed a significantly larger mitral valve area after FR (P=0.029). The regurgitation regression rate was 94% under mild MR in the FR group (1 case; severe) and 88.8% in the TR group (2 cases; moderate) during the same duration. CONCLUSIONS: Both techniques showed comparable outcomes and durability. However, FR is relatively simple and it is possible to re-initiate FR procedures; thus, it may also provide an opportunity for less-experienced surgeons to conduct valve repair surgeries. The study was registered with the University Hospital Medical Information Network (study ID: UMIN000039041).

Management of acute pulmonary embolism after acute aortic dissection surgery.

Acute aortic dissection (AAD) continues to be associated with high mortality and morbidity. Pulmonary embolism is also a life-threatening disease. The treatment of these life-threatening diseases remains controversial in case complications arise. Thrombolytic therapy and intensive treatment would be needed to manage these fatal diseases. A 49-year-old man with progressive back pain was admitted to our hospital. Computed tomography (CT) scan revealed type A AAD. Emergency operation for hemiarch replacement was performed. Two weeks postoperatively, the patient's oxygenation worsened and his d-dimer levels elevated. CT scan revealed a massive thrombus in the bilateral pulmonary arteries. Intensive anticoagulation therapy was started immediately. On postoperative day 27, the patient was weaned from mechanical ventilation, but the false lumen with thrombus was recanalized again. The patient was discharged on postoperative day 75 without resulting in major complications for aortic dissection. The diagnosis of pulmonary embolism concomitant with AAD is difficult. The treatment of pulmonary embolism after AAD is controversial. Our strategy seems to be suitable for acute pulmonary embolism that occurs during the treatment of AAD. ˂Learning objective: The diagnosis of pulmonary embolism concomitant with acute aortic dissection (AAD) is difficult. The treatment of pulmonary embolism after AAD is controversial. Investigating factor XIII levels might help in the early detection of pulmonary embolism.>.

Successful sparing approach between the ascending aorta and the main pulmonary artery to the giant coronary aneurysm of the left main coronary artery.

Coronary aneurysm located just above the left main coronary artery (LMT) is rare and difficult to treat. How the aneurysm is accessed is very important as it determines the result of the surgery. A 70-year-old man with a large coronary aneurysm (40 mm in diameter) in the LMT underwent surgery to prevent its rupture; however, there was severe adhesion. Initially, dissection of the ascending aorta or the pulmonary artery seemed necessary to access the aneurysm; however, the process was possible with limited dissection between the ascending aorta and the pulmonary artery, and we succeeded in firmly closing the LMT site of entry.

Combining autologous peripheral blood mononuclear cells with fibroblast growth factor therapy along with stringent infection control leading to successful limb salvage in diabetic patient with chronic renal failure and severe toe gangrene.

Peripheral arterial disease (PAD) is a common complication of Diabetes Mellitus (DM) and often culminates in amputation of the affected foot. Pseudomonas aeruginosa infections associated with PAD are difficult to treat due to their multi-drug resistance. Herein we report a 38 year old male who reported with DM, chronic kidney disease (CKD) and rest pain of the right second toe in October 2011. He underwent percutaneous transluminal angioplasty (PTA) which was unsuccessful. The gangrene of the toes worsened and amputation of the right second toe was done. Bacteriological examination showed presence of P. aeruginosa which during the course of antibiotic therapy became multi-drug resistant. Gangrene and abscess of the foot worsened and amputation of the right third toe was performed. Then autologous peripheral blood mononuclear cell (PBMNC) therapy was performed but as infection control could not still be achieved, the fourth toe was amputated. A protocol of foot bath using carbonic water, local usage of antibiotics (Polymyxin-B), and basic fibroblast growth factor (b-FGF) spray was then employed after which the infection could be controlled and improvement in vascularity of the right foot could be observed in angiography. This combined approach after proper validation could be considered for similar cases.

Right Aortic Arch and Kommerell's Diverticulum Repaired without Reconstruction of Aberrant Left Subclavian Artery.

Right aortic arch with Kommerell's diverticulum is a very rare situation. Surgical treatment is recommended for symptomatic patients or asymptomatic patients with a large diverticulum. However planning the strategy of operation is difficult without a 3D imaging. We report a case of a 57-year-old man with right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. After a 3D-CT imaging, the patient underwent descending aortic replacement without reconstruction of aberrant left subclavian artery. After operation, there was no signs or symptoms of ischemia of the left arm. If the reconstruction of the aberrant subclavian artery was too difficult, closing its orifice is an acceptable decision. It has been found advantageous because of a decrease blood loss and a shorter cardiopulmonary bypass duration. If an ischemia of the arm is noticed, additional reconstruction will have to be considered. 3D-CT imaging was very useful to have a proper orientation and plan for the operative strategy.

Prognostic factors affecting clinical outcomes after coronary artery bypass surgery: analysis of patients with chronic kidney disease after 5.9 years of follow-up.

BACKGROUND: Coronary artery bypass grafting (CABG) is a highly successful treatment for prolonging the lives of selected patients; however, preoperative and postoperative renal dysfunction has been an important predictor of adverse cardiovascular events. Concerns have recently grown regarding chronic kidney disease (CKD), which is an independent risk factor for cardiovascular diseases. In the present study we examined the significance of renal function on the basis of the estimated glomerular filtration rate (eGFR) and analyzed other factors as predictors of long-term clinical outcomes after CABG. METHODS: The subjects were 195 patients who underwent CABG from July 1996 through September 2008 at our hospital. Patients who received preoperative dialysis or who died during hospitalization or both were excluded. The patients were divided into 2 groups based on eGFR at the time of discharge (eGFR ≥60 mL/min/1.73 m(2): non-CKD group; or eGFR <60 mL/min/1.73 m(2): CKD group), and long-term outcomes were compared between the groups. The effects of other risk factors on long-term morbidity and mortality were also examined. RESULTS: The mean age of patients was 64.6 ± 9.3 years, and the mean duration of follow-up was 69.5 ± 44.5 months. There were no significant differences in either deaths from all causes or cardiovascular deaths between the CKD group and the non-CKD group. Multivariate analysis using the Cox proportional hazards model revealed that age (hazard ratio, 1.044; p=0.001) was a predictor of all-cause death and that age (hazard ratio, 1.154; p<0.001), diabetes mellitus (hazard ratio, 3.122; p=0.046), unstable angina (hazard ratio, 5.012; p=0.003), and proteinuria (hazard ratio, 7.982; p<0.001) were predictors of cardiovascular death. conclusions: Our study demonstrates that age, diabetes mellitus, unstable angina, and proteinuria are factors that affect long-term prognosis after CABG, whereas eGFR <60 mL/min/1.73 m(2) is not a predictive risk factor for either all-cause death or cardiovascular death. Although the predictive value of eGFR <60 mL/min/1.73 m(2) is generally accepted, analysis of our own data with receiver operating characteristic curves shows that eGFR <50 mL/min/1.73 m(2) is a more sensitive predictor of long-term outcome.

Left retroperitoneal approach using a retractor to repair abdominal aortic aneurysms: a comparison with the transperitoneal approach.

PURPOSE: The purpose of this study was to compare the effectiveness of the retroperitoneal approach (RP) using a Thompson retractor with the conventional transperitoneal approach (TP), to repair infrarenal abdominal aortic aneurysms (AAA). METHODS: A total of 91 consecutive patients were divided into two groups; group A ( n = 21) underwent surgery using the TP, and group B ( n = 70) underwent surgery using the RP with a Thompson retractor. RESULTS: There were no significant differences in the operation time, aortic cross-clamp time, incidence of postoperative cardiac events, or the development of wound complications; however, a significantly higher rate of postoperative respiratory complications and ileus was observed in group A. Moreover, oral feeding was commenced later and the hospital stay was prolonged in group A ( P < 0.01). CONCLUSION: These findings clearly demonstrate that our RP method, especially when using a Thompson retractor, is a preferable alternative to TP for AAA surgery.