Traumatic Tricuspid Insufficiency Requiring Valve Repair in an Acute Setting.

Tricuspid insufficiency due to penetrating cardiac trauma is rare. Patients with tricuspid insufficiency due to trauma can tolerate this abnormality for months or even years. We report a case of a 66-year-old female with penetrating cardiac trauma on the right side of her heart that required tricuspid valve repair in an acute setting. She sustained cut and stab wounds on her bilateral forearms and in the neck and epigastric region. She had cardiac tamponade and developed pulseless electrical activity, which required emergency surgery. The right ventricle and superior vena cava were dissected approximately 5 cm and 2 cm, respectively. After these wounds had been repaired, the patient's inability to wean from cardiopulmonary bypass suggested rightsided heart failure; transesophageal echocardiography revealed tricuspid insufficiency. Right atriotomy was performed, and a detailed examination revealed that the tricuspid valve septal leaflet was split in two. There was also an atrial septal injury that created a connection with the left atrium; these injuries were not detected from the right ventricular wound. After repair, weaning from cardiopulmonary bypass with mild tricuspid insufficiency was achieved, and she recovered uneventfully. This case emphasized the importance of thoroughly investigating intracardiac injury and transesophageal echocardiography.

[Surgical management of metastatic colon cancer causing obstruction of the right ventricular outflow tract].

Metastatic cardiac tumors are commonly detected during autopsy. However, they are seldom diagnosed during life, and surgical resection is rarely indicated. Among the malignant tumors, colon cancer rarely metastasizes to the heart. We report a case of a 70-year-old woman with sigmoid colon cancer, which metastasized to her heart and caused obstruction of the right ventricular outflow tract. The tumor had already metastasized to the liver, lungs, periaortic lymph nodes, and peritoneum. Cardiopulmonary bypass surgery was performed to excise the right ventricular metastatic tumor and to reconstruct the tricuspid valve. Histological analysis of the specimen confirmed a metastatic adenocarcinoma. Although this surgery was performed as palliative cancer therapy, the patient's symptoms were satisfactorily improved. Follow-up echocardiography 2 months after her cardiac surgery showed no space-occupying mass in the right ventricle.

[Toward a paradigm for universal procedures of valve repair].

We developed novel methods to simplify valve repair techniques.Adequate exposure is crucial for mitral valve surgery. The right side of the pericardium is sutured to the chest wall, and both cava are mobilized and hitched up to the left. Then a longitudinal incision of the right side of the left atrium allows excellent exposure of the mitral valve.We have developed a new device for replace neochordae. This double-armed, double-hooked device is inserted through the loop formed by the neochordae, which is anchored on the papillary muscle and pass through the prolapsing segment. The device pulls up both leaflets and maintains the neochordae at the same length as that of the opposing normal chordae during tying slippery neochordae.A simple method to repair large prolapsing posterior leaflet was developed. The middle of the prolapsed portion is cut, and both sides are laid each other. The water test is made to confirm accurate closure,and 2 layers are sutured.A novel method for adjustable tricuspid annuloplasty was developed. A flexible annuroplasty band,through which an expanded polytetrafluoroethylene (ePTFE) thread was passed, was secured to the tricuspid annulus. The thread was snared from outside of the ejecting heart under observation by echocardiogram.

Acquired pseudoaneurysm of the sinus of Valsalva.

Localized aneurysms of the sinus of Valsalva are uncommon. Repair is tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery. Herein, we report the successful surgical treatment of 2 patients who had unruptured pseudoaneurysms of the sinus of Valsalva. An evident fissure in the intima of the sinus of Valsalva was seen in both patients. Patient 1 was a 57-year-old man with annuloaortic ectasia who was diagnosed with pseudoaneurysm of the right sinus of Valsalva. A thrombus that had formed in the pseudoaneurysm subsequently migrated into the right coronary artery. Aortic root remodeling was performed. Patient 2 was a 23-year-old man with a history of blunt chest trauma. He developed a pseudoaneurysm in the right sinus of Valsalva and tears on the aortic cusps. He underwent aortic valve replacement and repair of the Valsalva wall.

Endoscopic observation following aortic cusp plication.

In valve-sparing operations for aortic root aneurysms, the dilated aortic root is replaced by a vascular graft. However, cusp disorders remain in some cases. We observed closed cusps endoscopically, and an improvement in the cusp coaptation was seen following plication. One of our cases of aortic valve plication is reported here. A rigid thoracoscope and cannula for cardioplegia delivery were inserted from the distal end of the aortic graft, and the graft was inflated with cardioplegic solution, providing an endoscopic view of the closed aortic cusps. We believe that endoscopic observation of closing cusps in this way may help surgeons to learn and master the techniques used in cusp repair more rapidly.

Bacteremia causes mycotic aneurysm of the aortic arch in 110 days.

We report a surgical case of mycotic aneurysm of the aortic arch, the possible cause, and the growth of which were retrospectively determined. A 61-year-old man with diabetes mellitus, free of aneurysm had bacteremia develop that was caused by Staphylococcus aureus. A computed tomographic scan was taken 110 days afterward that revealed an aneurysm in his aortic arch. Total arch replacement was performed, and S. aureus was detected in the aneurysm content. We conjectured that bacteremia caused mycotic aneurysm by day 110. The results of intraoperative microscopic examination also led the authors to decide on a regime for the immediate systemic administration of antibiotics.

Graft-to-coronary-artery shunt during off-pump coronary artery bypass grafting.

We have developed a simple technique for temporary shunt from the saphenous vein graft to the coronary artery during off-pump coronary anastomosis. The ends of a 2-mm diameter tube were inserted into the distal end of the saphenous vein graft in which proximal anastomosis had been established and into the right coronary artery crux. Blood flow sufficient to maintain adequate hemodynamics was obtained through the shunt tube while suturing around the tube. We successfully employed this technique in 5 patients with acute coronary syndrome. We suggest that this technique may represent an addition to the armamentarium for off-pump anastomosis to the right coronary artery.

Nonprosthetic surgical repair of pectus excavatum.

BACKGROUND: Previously, a method was reported to correct pectus excavatum in which a convex steel bar is inserted beneath the sternum. This method gained popularity, but a relatively high incidence of complications has been reported. We review our experience of nonprosthetic repairs of pectus excavatum. METHODS: From 1993 through 2004, 62 patients underwent repair of pectus excavatum. Sternocostal elevation was adopted for 54 patients (11.7 +/- 8.3 years old). A part of the third or fourth to the seventh costal cartilages was resected. All of the stumps were pulled to generate tension and resutured with the sternum. Cortical osteotomy of upper sternum and introduction of exogenous material were not employed. Sternal turnover and overlap was adopted for 8 adults (24.1 +/- 9.0 years old) with severe asymmetric deformities. The sternum was cut at the level of the second or third intercostal space. The lower part of the sternum was turned over and secured in a position so that it overlapped with the upper sternum, and the stumps of cartilages were reattached to the plastron. In these procedures, the natural tension exerted by the patient's ribs is sufficient to elevate and fix the sternum. RESULTS: Mechanical ventilation was not required after emergence from anesthesia. None of the patients experienced threatening complications or required reoperation. Fifty patients (81%) were graded as excellent, and 12 patients (19%) were graded as good at 1 month after surgery. CONCLUSIONS: The procedures described here yielded excellent results with low morbidity and no mortality, and produced high patient satisfaction.

A case of fistula of the right common iliac aneurysm to the appendix.

We report a very rare case of spontaneous ilioappendicial fistula with right common iliac aneurysm. After the aneurysm was opened, afferent and efferent vessels were closed following extraanatomical femorofemoral bypass, and the appendectomy was performed. The wall of the aneurysm showed the atherosclerotic change and histologic study of the appendix confirmed the diagnosis of acute appendicitis. Enhanced computed tomography was useful for the diagnosis and the extraanatomical bypass was deemed the most effective operative strategy. The pathogenesis of the fistula was surmised to be related to the appendicitis.

Total aortic arch grafting for acute type A dissection: analysis of residual false lumen.

BACKGROUND: In surgery for acute type A dissection, an unresected dissection and residual false lumina are causes of the progression of aneurysms and ruptures. We grafted the ascending aorta and total arch, the maximum grafting possible through a median sternotomy alone, in all patients with type A dissection extending to the descending aorta, wherever initial tears existed in the arch. METHODS: A total of 37 consecutive patients with acute type A dissection underwent ascending and total arch grafting between August 1994 and December 2000. Cerebral protection was achieved by selective cerebral perfusion. The distal anastomosis was conducted using the "Elephant Trunk" technique. Patent false lumina were evaluated using computed tomography 3 months after the operation. RESULTS: The hospital mortality was 8.1%. No major cerebral complications were observed. The incidence of residual thoracic patent false lumina was 26.5%. Univariate analyses showed Marfan syndrome and preoperative extension of false lumina to be statistically significant determinants of residual thoracic false lumina. On multivariate analysis, no other significant independent predictor of residual false lumina in the thoracic aorta was found. CONCLUSIONS: Outcomes of our strategy were satisfactory. However, residual thoracic false lumina could not be prevented in 26.5% of the patients. Thus, this extended operation is indicated in patients with initial tears in the aortic arch or distal arch, those with Marfan syndrome, and young patients with preoperative patent false lumina extending to the abdominal aorta.