[Pulmonary embolectomy for acute massive pulmonary thromboembolism after failure of thrombolytic therapy].

Acute massive pulmonary thromboembolism (PTE) is associated with an exceptionally high mortality rate and results in death if not diagnosed early and treated properly. We observed 3 cases of acute massive PTE. One of the patients had undergone a surgery for femoral neck fracture. Ten days postoperatively, she developed severe dyspnea with hypoxia, and computed tomography (CT) pulmonary angiography confirmed the PTE diagnosis. She then had cardiac arrest when catheter examination. Although emergency surgical thrombectomy was successful with good postoperative hemodynamic stability and oxygenation, the patient did not recover from the unconsciousness caused by preoperative ischemic brain damage. Subsequently, she died 6 months after surgery. Of the 3 patients, 2 suffered from right ventricular dysfunction without hemodynamic instability. They underwent open thrombectomy after the failure of conservative treatment with a systemic injection of urokinase. Both patients demonstrated a good clinical course and were discharged from hospital in a good general condition 22 and 28 days postoperatively. Herein, we review the current literature on PTE treatment. We concluded that an aggressive surgical intervention might be preferred to thrombolytic therapy for PTE patients with massive thrombosis and progressive right ventricular dysfunction.

[The ischemic mitral valve regurgitation due to acute coronary thromboembolism; report of a case].

A 71-year-old man with congestive heart failure due to acute myocardial infarction was referred to our hospital. He was under the support of mechanical ventilation and the intraaortic balloon pumping (IABP) and coronary angiogram revealed the thromboembolism of the obtuse marginal artery. We completed the revascularization by the direct percutaneous coronary intervention. However, grade II mitral valve regurgitation and heart failure were worsening. Mitral valvuloplasty and the modified maze procedure through the partial lower sternotomy were performed. He is still in good condition 4 years later. Ischemic mitral valve regurgitation due to the coronary thromboembolism is very rare. Careful follow-up on the grade of ischemic mitral valve regurgitation is necessary even after the early coronary recanalization. The surgical approach of the partial sternotomy should be used in such a case of acute mitral valve regurgitation.

Autologous pericardial patch repair for postinfarction ventricular septal perforation.

Surgical therapy for ventricular septal perforation associated with acute myocardial infarction is thought to reduce ventricular chamber volume and distort the ventricle due to excision of the myocardium. A 69-year old man underwent elective surgery that used an autologous pericardial patch without excising the myocardium. Intraventricular repair using the autologous pericardial patch enabled preservation of ventricular geometry and chamber volume and did not result in a depression of cardiac function. Moreover, it has been reported that this surgical procedure protects against suture bleeding and decreases the amount of foreign material required, thus possibly reducing the risk of infectious complications.

[Urgent mitral valve replacement for acute mitral regurgitation due to ruptured chordae tendineae in systemic lupus erythematousus].

We reported a successful surgical treatment of mitral regurgitation (MR) due to ruptured chordae tendineae in a 44-year-old man with systemic lupus erythematosus (SLE) who had received the steroid therapy. He had signs of acute congestive heart failure with severe pulmonary hypertension due to MR, and underwent urgent mitral valve replacement. The postoperative course was uneventful. When replacing valve in SLE, a careful manipulation should be taken because of friability of cardiovascular tissue. Patients are usually administered steroid agents, and the agents ought to be discontinued in perioperative period, but it seems to be better to resume as soon as possible. We conclude that the surgical treatment for valvular diseases should be considered, even in the patient with SLE.

Assessment of left ventricular diastolic function in chronic mitral regurgitation by Doppler left ventricular inflow and left ventricular ultrastructural morphometry.

Doppler left ventricular (LV) inflow is reportedly affected by LV diastolic properties. We evaluated 48 subjects consisting of 27 patients with chronic mitral regurgitation (MR) and 21 patients with noncardiac disorders who received echocardiographic examinations. The deceleration rate divided by diastolic dimension (DR/Dd) derived from Doppler early diastolic LV inflow was correlated with the peak diastolic velocity divided by diastolic dimension (peak DV/Dd), a conventional index of LV diastolic function derived from the M-mode echocardiogram in the 48 patients, regardless of the presence of normal sinus rhythm or atrial fibrillation. LV diastolic function was then estimated by comparing perioperative echocardiographic examination and LV micro-and ultrastructural findings of biopsy specimens from 12 patients with MR who received mitral valve replacement. Fiber diameter, volume fraction of interstitial fibrosis (int. % Fib), and volume fractions of three intracellular components; the myofibrils (% MF), the sarcoplasmic reticulum (% SR) and the mitochondria (% MT), were measured in LV transmural biopsy specimens. DR/Dd was significantly correlated with peak DV/Dd before and after operation. Peak DV/Dd and DR/Dd were inversely correlated with int. % Fib and % SR, and were positively correlated with % MF. We subdivided the 12 MR patients according to their postoperative DR/Dd values as "recovered", and "non-recovered" based on their postoperative LV diastolic function. % MF was significantly lower in the 'non-recovered' group. Thus, DR/Dd can serve as an index of LV diastolic function. A decrease in % MF may inhibit the recovery of postoperative LV diastolic function.

[Report of three cases of emergency surgical salvage for acute pulmonary embolism].

Pulmonary embolism (PE) is one of the increasing diseases in Japan, which is aggravated rapidly and early diagnosis is necessary to improve its prognosis. We experienced three cases of successful surgical salvage. It is emphasized that the Doppler ultrasonic echocardiography plays important part in diagnosing PE early and noninvasively. Namely, it shows a appearance of acute cor pulmonale, and is usually able to guess the pulmonary artery pressure by using the simplified formula of Bernoulli's equation. We believe that the surgical pulmonary embolectomy under the cardiopulmonary bypass should be immediately considered in case of unsatisfactory conservative thrombolytic therapy.

Factors influencing the efficacy of DeVega's annuloplasty for secondary tricuspid regurgitation.

DeVega's annuloplasty was performed on 41 patients with tricuspid regurgitation (TR) associated with combined valvular disease and results were assessed based on Doppler echocardiographic findings in an attempt to examine the applicability of this surgical technique. TR was quantitatively evaluated via Doppler echocardiography before and after surgery. Clinical symptoms, cardiac function, and surgical results were assessed, and the severity of left ventricular myocardial degeneration was determined using electron microscopy. There were no differences in the following factors between the TR recurrence and TR improvement groups: previous heart surgery, number of involved valves, presence or absence of a giant left atrium, preoperative New York Heart Association (NYHA) functional class, and type of prosthetic valve (Björk-Shiley vs. St. Jude Medical). We found no differences between these two groups in TR severity and tricuspid annulus diameter measured during surgery. Severity of myocardial degeneration was closely associated with the recurrence of TR. Clinically, most had diminished cardiac function before surgery. DeVega's technique appears to be remarkably effective in patients with well-preserved myocardium because no TR recurrence was detected even in examinations with the most accurate Doppler echocardiography. However, such long-term effectiveness of DeVega's technique cannot be expected in patients with degenerated myocardium.

[A case of the emergency salvage from the thrombotic occlusion of the Fontan conduit in tricuspid atresia].

The thrombotic occlusion of the Fontan conduit is one of the most fatal complications after Fontan procedure. Its survival case by the successful emergency surgery is reported. A 17-year-old male who had undergone Fontan procedure three years before for tricuspid atresia, using the expanded PTFE graft of 19 mm in internal diameter, had several episodes of palpitation due to probable paroxysmal atrial fibrillation. He suddenly complained chest oppression feeling and suffered paroxysmal atrial tachycardia following after atrial fibrillation. The radionuclide angiocardiography was performed immediately, which revealed clearly that the Fontan conduit had occluded by the thromboembolism in spite of the prophylactic anticoagulant therapy. Then the emergency surgery was performed successfully, in which the occluded Fontan conduit was replaced with another expanded PTFE graft of 20 mm in internal diameter under the extracorporeal circulation. It seemed that the inducement of this thrombotic occlusion of the Fontan conduit was paroxysmal atrial fibrillation. We emphasize the importance of the prevention of arrhythmias in the postoperative care of the Fontan procedure. Additionally we do emphasize the usefulness of the radionuclide angiocardiography which is available and non-invasive. Especially, first-pass study is much informative to elucidate the circulatory states in the cardiac anomalies.