[Left ventricular outflow tract obstruction after mitral valve plasty; report of a case].

A 65-year-old female was admitted to our hospital with mitral regurgitation (MR). Transthoracic echocardiography showed severe mitral valve prolapse and subaortic septal hypertrophy with no pressure gradient. Mitral valve plasty consisted of artificial chorda implantation and ring annuloplasty was performed. During intensive care unit( ICU) stay after operation, systolic murmur and low cardiac output syndrome were noted and echocardiography revealed left ventricular outflow tract obstruction (LVOTO) without systolic anterior motion and MR. Cessation of catecholamine, volume administration, beta-blocker and negative inotropic drug like cibenzoline rapidly reduced LVOTO and the hemodynamic condition was improved. Even in a case of subaortic septal hypertrophy with no pressure gradient, emergence of LVOTO should be considered when new systolic murmur and low cardiac output syndrome appeared.

[Modified warden procedure for partial anomalous pulmonary venous connection in an adult].

A 46-year-old woman was admitted to our hospital because of congestive heart failure and atrial fibrillation. She had undergone atrial septal defect repair at the age of 7 years. Computed tomography( CT)scan revealed right upper pulmonary vein returned to superior vena cave and the left upper pulmonary vein returned to the innominate vein. Cardiac catheterization showed Qp/Qs of 2.6. Pulmonary venous drainage repair and right-sided maze procedure was planned. The right upper pulmonary vein was led to the left atrium using the modified Warden Procedure. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Concomitantly right-sided maze procedure was performed. Postoperative course was uneventful and CT scan revealed no stenosis at anastomotic sites. Sinus rhythm was retained and she was discharged on postoperative day 30.

[Large cell neuroendocrine carcinoma of the thymus; report of a case].

A 55-year-old man presented with an anterior mediastinal tumor, which was detected on a computed tomography scan for close investigation of blood-stained sputum. Operation was performed with the clinical diagnosis of a thymic carcinoma and the tumor was resected completely. The pathological findings revealed Masaoka stage IV, large cell neuroendocrine carcinoma of the thymus. The patients received postoperative chemotherapy and is well without recurrence for 10 months after the surgery.

[Aortopulmonary fistula caused by aortic arch aneurysm rupture presenting severe left to right shunt and congestive heart failure].

A 74-year-old female was admitted to our hospital due to hyperkinetic congestive heart failure. Noninvasive positive pressure ventilation, continuous hemodialysis and inotropic support were needed preoperatively. Computed tomography revealed saccular aortic arch aneurysm with aortopulmonary fistula toward the left pulmonary artery. Cardiac catheterization revealed severe left to right shunt with the pulmonary flow/systemic flow (Qp/Qs) ratio of 6.2.Emergency operation was performed under hypothermic circulatory arrest followed by selective cerebral perfusion and lower body perfusion. The aortopulmonary fistula was directly closed, reinforced with the aneurysmal wall, and total arch replacement was performed. Although the patient temporarily recovered by endoscopic suction of the blood from the lungs and continuous hemodialysis filtration, she died because of multiple organ failure due to mesenteric ischemia on postoperative day 34.

[Effectiveness of simultaneous cardiac resynchronization therapy in surgical valvular patients with severe heart failure].

BACKGROUND: Cardiac resynchronization therapy (CRT)has been accepted broadly as an alternative to medical treatment in managing severe heart failure patients. Despite advance in CRT, the presence of a significant valvular heart disease was currently specific exclusion criteria and a response to this therapy remains unclear. The purpose of this study was to determine the effectiveness of CRT in heart failure patients undergoing valvular operation simultaneously. PATIENTS AND METHODS: Between July 2010 and May 2012, 8 heart failure patients who underwent CRT in conjunction with valvular surgery were experienced. Right and left ventricular and atrial epicardial leads were implanted after completion of valvular procedures. In patients with chronic atrial fibrillation(Af),maze procedure was performed in order to eliminate Af. To evaluate the improvement of ventricular mechanical dyssynchrony, the echocardiographic assessment was repeated on admission and 1 month after the CRT implantation. RESULTS: There was no operative death. One patient of ischemic cardiomyopathy died of sustained ventricular tachycardia 2 months after the operation. Postoperative course of severe heart failure patients was uneventful and all patients except 1 discharged on foot with improved New York Heart Association (NYHA) class. Echocardiographic parameters of dyssynchrony did not reach to statistical significance, but several parameters, left ventricular( LV)-pre-ejectionperiod( PEP) and interventricular mechanical delay (IVMD) showing time delay of cardiac contraction, tended to be improve, suggesting contribution to satisfactory postoperative course. CONCLUSION: The acceptable outcome was demonstrated with our concept to recover the intraventricular and atrioventricular synchrony. Although it might be difficult to establish the patient selection criteria for concomitant CRT and valvular surgery, our strategy is considered to be a feasible procedure to improve the morbidity and mortality in patients with severe heart failure due to valvular disease.

Port-access thoracoscopic anatomical lung subsegmentectomy.

OBJECTIVES: The diagnosis of small lung nodules has increased in recent years; limited resection and minimally invasive surgery are highly desirable in patients with these lesions. While wedge resection may be curative for small lung nodules, the technique is sometimes difficult to perform when the tumour nodule is near the pulmonary hilum. In such situations, either anatomical segmentectomy or subsegmentectomy can obtain an adequate surgical margin; port-access thoracoscopic surgery is the preferred type of minimally invasive surgery. Three-dimensional (3D) computed tomography (CT) simulations are reportedly useful in planning and performing thoracoscopic surgery. We use 3D CT simulation to aid thoracoscopic segmentectomy for small lung nodules and subsegmentectomy for even smaller nodules and conduct here a retrospective evaluation of the clinical results of subsegmentectomy. We present our technique for 3D CT simulation-assisted port-access thoracoscopic subsegmentectomy in the superior segment of the left lower lobe. METHODS: Between July 2008 and June 2012, 15 patients underwent port-access thoracoscopic subsegmentectomy. We evaluated the pathological diagnoses, the tumour sizes, the indications, the operative times and the volumes of blood loss. RESULTS: Seven patients were diagnosed with lung cancer (LC) and eight had metastatic lung tumours (MLT). The median tumour size was 12 mm. The indication for using this surgical technique was to secure surgical margins in 13 patients (LC, 6; MLT, 7) and because of poor surgical risk in two patients (LC, 1; MLT, 1). The mean surgical time was 166 min and the median blood loss was 19 ml. There were no recurrences. CONCLUSIONS: Port-access thoracoscopic lung subsegmentectomy using 3D CT simulation can be safely performed and is able to secure adequate surgical margins.