Thoracic endovascular aortic repair with a right thoracotomy approach.

BACKGROUND: The common femoral artery is usually the preferred access route for thoracic endovascular aortic repair (TEVAR). However, if access from the common femoral artery is challenging, other routes must be considered. We report a case of TEVAR performed by approaching the descending thoracic aorta with a right thoracotomy and using the descending thoracic aorta as an access route. CASE PRESENTATION: A 70-year-old female was diagnosed with a descending thoracic aortic aneurysm (65 mm in diameter), a thoracoabdominal aneurysm (54 mm in diameter), and an abdominal aortic aneurysm (49 mm in diameter). Since the patient had severe chronic obstructive pulmonary disease, one-stage replacement of the thoracoabdominal aortic aneurysm was contraindicated and TEVAR on the descending aorta was selected. A strong tortuous section of the aorta-from the descending aorta to the abdominal aorta-hampered endovascular access to the site from the common femoral artery. A TEVAR approach from the abdominal aorta was also considered; however, an abdominal aortic aneurysm and a transverse colon loop stoma from an earlier surgery presented challenges to this technique. We chose to access the descending thoracic aorta with a thoracotomy from the right 6th intercostal space for TEVAR, because the access route that is not affected by the meandering of the aorta is considered to be the descending aorta with a right thoracotomy. The patient's postoperative course was uneventful after the stent graft was placed. No complications were detected with postoperative contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings suggest that TEVAR can be performed by approaching the descending aorta from a right thoracotomy, if variations of vascular anatomy interfere with the more commonly used femoral artery approach.

[Prediction of Length of Artificial Chordae by Using Preoperative Cardiac Computed Tomography:Report of a Case].

A 51-year-old man was diagnosed as having mitral valve regurgitation( MR). Transesophageal echocardiography revealed severe MR due to A2 prolapse. We decided to perform a mitral valve plasty (MVP). The length of an artificial chord was estimated by measuring the distance from the anterior and posterior papillary muscles to A2 on cardiac computed tomography (CT). The operation was performed with a median sternotomy. The leaflet prolapse lesion was localized in A2, and one torn chord was revealed. Polytetrafluoroethylene sutures were fixed to the papillary muscle, and markings were performed. After fixing the artificial chord to A2 in the predicted length before the operation, a leakage test was performed. We confirmed that the MR had disappeared. The postoperative course was good, and no MR was detected upon postoperative echocardiography. Preoperative prediction of the artificial chord length using cardiac CT is useful because it can be adjusted relatively easily.

[Refractory Hypertension and Intermittent Claudication Caused by Distal Elephant Trunk Stenosis 10 Years After Total Arch Replacement for Stanford Type A Aortic Dissection;Report of a Case].

A 49-year-old man was admitted to our hospital because of intermittent claudication and refractory hypertension 10 years after surgery to Stanford type A acute aortic dissection. He underwent total arch replacement with an elephant trunk of 22 mm in diameter. Transesophageal echocardiography revealed that distal end of the elephant trunk was stenosed. Systolic blood pressure gradient over this portion reached to more than 100 mmHg. Folding of elephant trunk and thrombus formation were considered to be the cause. Thoracic endovascular aortic repair relieved stenosis and intermittent claudication, and enabled better blood pressure control.

Intermediate-term outcomes of our original multiple-knot technique using ePTFE sutures for anterior mitral leaflet prolapse.

PURPOSE: To define the outcomes of our original simple chordal replacement technique using ePTFE sutures for mitral regurgitation. METHODS: Between January, 2004 and March, 2014, 38 patients underwent mitral valve repair using our chordal replacement technique for anterior leaflet prolapse. The mitral regurgitation was caused by degenerative disease in 34 patients and infective endocarditis in 4 patients. RESULTS: The follow-up period was 66 ± 37 months and the 5-year survival rate was 95 ± 4%. Two patients had recurrent mitral regurgitation, caused by degenerative change not associated with the procedure. The 5-year rate of freedom from recurrent mitral regurgitation was 94 ± 4%. In the late postoperative period, 15 (42%) patients had a mean pressure gradient > 5 mmHg. Stepwise logistic regression analysis showed that the use of a full ring (odds ratio 8.9; 95% confidence interval 1.2-64; p = 0.031) and a 26 mm annuloplasty (odds ratio 7.5; 95% confidence interval 1.1-50; p = 0.037) were significant independent risk factors for a mean pressure gradient > 5 mmHg. CONCLUSION: The intermediate-term outcomes of our original chordal replacement technique were not inferior to those in previous reports, although a 26 mm annuloplasty was found to be associated with a higher mitral valve gradient at rest.

[Cardiac tamponade due to ruptured coronary artery aneurysm associated with coronary-pulmonary artery fistula; report of a case].

We report a successful operative treatment of ruptured coronary artery aneurysm associated with coronary-pulmonary artery fistula. A 67-year-old woman was diagnosed with coronary artery fistula previously but observed without any treatment. She had medical examination at a previous hospital because of sudden onset of dyspnea, and transported to our institution with a diagnosis of cardiac tamponade. Multi-detector computed tomography (MDCT) showed massive pericardial effusion, coronary-pulmonary artery fistula and giant coronary artery aneurysm. We performed emergency operation. Under cardiopulmonary bypass, coronary artery fistula and aneurysm was resected. Postoperative MDCT showed almost complete exclusion of coronary artery fistula. Postoperative course was uneventful.

Surgical repair of aberrant subclavian artery through clamshell approach.

Aberrant subclavian artery is a rare abnormality that often occurs in association with Kommerell's diverticulum. The optimal surgical treatment is exclusion and reconstruction of the dilated diverticulum or aberrant subclavian artery. To accomplish such a radical operation in a single stage, we have introduced total (or partial) arch replacement using deep hypothermic circulatory arrest and the arch-first technique through a bilateral submammary thoracotomy (the clamshell approach). This technique provides excellent exposure of the neck arteries and the entire thoracic aorta.

Aortoventricular disruption after aortic valve replacement: a rare complication.

Aortoventricular disruption after aortic valve replacement is extremely rare. A case of aortoventricular disruption following aortic valve replacement is described in detail, and related case reports are reviewed. A 76-year-old male underwent aortic valve replacement with a tissue valve using everting mattress sutures, repair of the ascending aortic aneurysm, and mitral valve repair. After cardiopulmonary bypass was terminated, pulsatile bleeding behind the aortic root was observed, which required cardiopulmonary bypass. The ventricular rupture was located just below the left coronary annulus, and appeared secondary to a tear through the ventricular myocardium by the valve sutures. The tear was internally repaired by pledgeted sutures and Dacron patch reinforcement. The patient recovered and was discharged without major complications. Although this serious complication is extremely rare, surgeons should be aware that deep everting stitches on the left coronary annulus potentially causes aortoventricular disruption. Overstretching the posterior aortoventricular junction may contribute to this type of injury.

Transaortic correction of systolic anterior motion of the mitral leaflet after aortic and mitral valve replacement.

Left ventricular outflow tract obstruction is a rare and critical complication after mitral valve replacement. We report a patient who presented with severe left ventricular outflow tract obstruction caused by systolic anterior motion of the native mitral leaflet after aortic and mitral valve replacement. The patient was successfully treated by resection of the anterior mitral leaflet through the 19-mm bioprosthetic valve in the aortic position. This approach is quite simple and effective, even through the small aortic bioprosthesis, and does not require a second mitral valve replacement.

Early aortic bioprosthetic valve deterioration in an octogenarian.

We experienced extremely early aortic bioprosthetic valve deterioration with leaflet calcification and stiffening 2 1/2 years after aortic valve replacement in a female octogenarian. We could not identify the possible reason for this devastating complication; however, daily calcium supplement consumption may play a role of acceleration of calcium deposition in the leaflets of implanted bioprosthetic heart valves.

Left ventricular thrombus with a normal heart.

A 44-year-old man was found to have a left ventricular mass by transthoracic echocardiography. He had had multiple events of systemic embolization over the last few years. The heart was not dilated, and heart function was normal. Surgical excision was recommended to avoid further embolization. A transverse aortotomy was carried out under cardioplegic cardiac arrest with standard cardiopulmonary bypass. A transaortic video-assisted endoscopic procedure was performed. The mass was resected endoscopically without left ventriculotomy. Pathologically, the excised mass was an organized thrombus with a fibrous stalk connected to endocardium. We thus report a case of left ventricular thrombus with a normally functioning heart.

Devastating late complication for repair of type A acute aortic dissection with usage of gelatin-resorcinol-formalin glue.

OBJECTIVES: We review cases of pseudoaneurysm formation of the graft anastomosis sites following repair of type A acute aortic dissection by our original leak-proof technique for dissected aortic wall reinforcement with xenopericardium and gelatin-resorcinol-formalin (GRF) glue. CASES: A 47-year-old male presented inferior acute myocardial infarction with bradycardia and cardiogenic shock 34 months after the initial total arch replacement for acute aortic dissection. The patient underwent reoperation with total arch replacement and coronary artery bypass grafting to the right coronary artery. There was rupture of the proximal anastomosis with clotted pseudoaneurysm formation extending over the right ventricle. The right coronary artery was compressed by the pseudoaneurysm. The distal anastomosis also ruptured with localized pseudoaneurysm formation. Twenty-two patients with type A acute aortic dissection underwent aortic repair by our original leak-proof technique for dissected aortic wall reinforcement with xenopericardium and gelatin-resorcinol-formalin glue between 1997-2003. Four patients developed redissection of the anastomosis sites, which required reoperation, including the current case. DISCUSSION: The cause of redissection was unclear, however, use of GRF glue itself might develop tissue damage and redissection of the aorta, and also glued xenopericardium strip reinforcement in our original technique might accelerate damage to the aortic wall. CONCLUSION: Follow-up examination is mandatory for the patient of aortic repair with the use of GRF glue.

Spontaneous right coronary artery pseudoaneurysm.

A 67-year-old man who had no history of coronary artery disease was found to have electrocardiographic abnormalities. Coronary angiography showed a proximal coronary artery aneurysm and total occlusion of the distal right coronary artery. He underwent coronary artery bypass grafting and repair of the right coronary artery aneurysm. The pathology of the resected aneurysm wall was compatible with a diagnosis of coronary pseudoaneurysm. Spontaneous coronary artery pseudoaneurysm is a rare condition that has the potential risk of rupture or ischemia. Surgical repair and adequate coronary revascularization are reasonable for a possible coronary artery pseudoaneurysm.