[Sudden Chest Pain due to Early Bioprosthetic Valve Dysfunction:Report of a Case].

We report a case of bioprosthetic valve dysfunction and acute aortic valve regurgitation. The case was a 75-year-old female who had sudden onset chest pain. ST-segment depression in several leads on electrocardiogram( ECG) suggested acute coronary syndrome. Coronary angiography showed no significant stenosis in coronary arteries. Transesophageal echocardiography revealed severe aortic regurgitation, suggesting that angina was caused by myocardial ischemia associated with acute aortic regurgitation. She was diagnosed as having bioprosthetic valve dysfunction, and underwent redo aortic valve replacement. One leaflet of the bioprosthetic valve was torn along the stent post and caused bioprosthetic valve dysfunction. Failed bioprosthetic valve was removed and replaced by a mechanical valve.

[Traumatic Ascending Aortic Injury with Delayed Cardiac Tamponade due to Sternal Fracture].

The case was a 63-year-old male. He had a history of surgery for funnel chest at the age of 23. He overdrank and hit the anterior chest about two weeks before. He complained of persistent chest pain and palpitation, and was admitted because of atrial fibrillation and moderate pericardial fluid. Computed tomography (CT) showed a new sternal fracture, but dislocation and instability was mild. A few days later, sinus rhythm was restored and his heart failure improved. Unfortunately, on the 7th day, he suddenly suffered cardiopulmonary arrest. Ultrasonography revealed cardiac tamponade, and pericardiocentesis yielded 400 ml of bloody pericardial fluid collection. CT demonstrated clot mainly in the anterior pericardium, and emergent operation was performed. Bleeding from the anterior wall of the ascending aorta was repaired by placing one stitch. Postoperatively the patient remained unconscious, and CT of the brain showed hypoxic encephalopathy. After prolonged ventilator management, he was transferred to a rehabilitation hospital. In retrospect, the ascending aorta was close to the sternum in this patient, and sternal fracture might have caused injury of the ascending aorta.

Efficacy of Plasma free Hemoglobin for detecting centrifugal pump thrombosis.

INTRODUCTION: Lactate dehydrogenase (LDH) is widely used as an indicator of pump thrombosis in a centrifugal pump. However, due to the low specificity of LDH, pump thrombosis is difficult to detect in the clinical environment. We measured plasma free hemoglobin (pfHb) with the portable device in ICU. The goal of this investigation is to evaluate its diagnostic ability for pump thrombosis. METHODS: We enrolled 31 consecutive patients who needed Extracorporeal Membrane Oxygenation (ECMO) therapy and pfHb was determined with HemoCue® plasma/Low Hb photometer. Pump thrombosis was analyzed macroscopically at the timing of pump explantation or exchange. Also, we divided the pump thrombosis into a grading scale by the place of thrombosis. RESULTS: The median of peak pfHb was significantly lower in the none thrombus group (0.03 g/dL) than that of in the thrombus group (0.05g/dL) (p = 0.01). In our grading criteria, pfHb was significantly higher when the thrombus is existing near the shaft (p = 0.015). Contrary, no significant difference was found for LDH.The ROC analysis of pfHb revealed an AUC of 0.77 for detecting pump thrombosis with the best statistical cutoff value at 0.05 g/dL (specificity, 78%; sensitivity, 77%). Also, ROC analysis of LDH was performed (AUC, 0.44; cutoff value, 1200 IU/L; specificity, 59%; sensitivity, 54%) and compared with pfHb. AUC was significantly higher in pfHb (p = 0.04). CONCLUSION: Our results showed the efficacy of pfHb for detecting centrifugal pump thrombosis.

Warfarin-induced toxic epidermal necrolysis after mitral valve replacement.

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare diseases that cause acute destruction of the epithelium of the skin and mucous membranes, almost always attributable to drugs. However, warfarin-induced Stevens-Johnson syndrome and toxic epidermal necrolysis is extremely rare. We report the case of 71-year-old woman who died due to destructive erosion all over her skin and mucous membranes. She had received a mitral valve prosthesis, and warfarin was prescribed for antithrombotic therapy. A lymphocyte transformation test for drug hypersensitivity and the clinical history confirmed this phenomenon as warfarin-induced toxic epidermal necrolysis.

Heparin 'flush' induced thrombocytopenia triggered by total hip replacement: a case report.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) typically responds to heparin termination. Some types of HIT can persist after heparin discontinuation. CASE SUMMARY: A 95-year-old woman was referred to the cardiology from orthopaedics because of acute limb ischaemia (ALI) 1 day after surgery of a femoral neck fracture. Despite thrombectomy, ALI relapsed the next day. She had been treated with intravenous antibiotics with a diagnosis of aspiration pneumonia for 1 week until 3 days before surgery, together with heparin flush twice a day. Of note, no intra-/post-operative heparin was administered, no cell salvage device, central venous, nor arterial catheters were used before development of ALI. The patient and her family refused reattempting invasive therapies; consequently, the patient continued to worsen and died on post-operative day 3. Diagnosis of autoimmune HIT, which was prompted by surgery without re-exposure to heparin, was confirmed posthumously. DISCUSSION: This case emphasizes the significance of suspecting autoimmune HIT in any patient presenting with thrombosis, even if the heparin exposure dates back more than a few days or even without heparin exposure.

Effect of an artificial ring on mitral valve function.

Differences of the effect of annuloplasty rings on the mitral annulus and leaflets, and differences between types of annuloplasty rings are not well known. We analyzed annular motion and leaflet movement with a rigid or flexible ring and without a ring using an isolated swine working heart model. Hearts of 10 swine (weight: 40-50 kg) were used for a rigid ring (n=5) and a flexible ring (n=5). Four ultrasound crystal tips were fixed around the annulus and an annuloplasty ring was implanted in the isolated heart. In the working heart mode, measurement of mitral annular dimension was acquired by sonomicrometry. Images of mitral valve motion were acquired by a high-speed video camera. The same analyses were performed after removing the artificial ring. The antero-posterior diameter of the diastole distance was significantly reduced in the flexible ring (21.59±0.71 mm) and rigid ring (15.93±1.88 mm) compared with no ring (23.51±2.01 mm). The flexible ring made the transverse diameter shrink significantly more than did the rigid ring. The contraction range of the transverse diameter was significantly smaller in the flexible ring compared with no ring. The duration of opening to closing of the mitral leaflet with the rigid (124.7±4.4 ms) and flexible rings (107.9±3.5 ms) was significantly shorter than that with no ring (168±36.5 ms). Annuloplasty rings allow simplicity of leaflet motion, regardless of the type of artificial ring. In a flexible ring, the mitral annulus shows a vertically long shape, suggesting preservation of posterior annular movement.

[Video Assisted Left Ventricular Pseudoaneurysm Repair].

An 80-year-old male was admitted to our hospital because of subacute myocardial infarction with moderate mitral regurgitation. Though he recovered well and went home within 2 weeks, the transthoracic echocardiography revealed rapid growing aneurysmal changes at the left ventricular posterior wall. We made diagnose of a pseudoaneurysm by the multi detector-row computed tomography, and planed a surgical treatment. Following the cardiac arrest, an endoscope was inserted into the left ventricle, we inspected the relation between the mitral valve and papillary muscles to detect proper suture lines and to avoid the mitral regurgitation. The defect of the left ventricular wall was repaired with 2-layer bovine pericardial patches reinforced with fibrin glue. His postoperative course was uneventful, and he was discharged from hospital on 12th postoperative day. We consider that inspections of intra-ventricle apparatus with the endoscope are useful to prevent the mitral valve insufficiency and keep the optimal left ventricle shape.

Giant biatrial myxoma with two different gross findings.

We experienced a giant biatrial myxoma concomitant with hepatocellular carcinoma. Most of myxomas originate from the left atrium, and biatrial myxomas are extremely rare. Excision of the giant cardiac tumor was performed to avoid risks of life-threatening complications. The resected mass was grossly composed of two parts with the border of interatrial septum and with the shape of peanut shell. Although microscopic examinations revealed enlarged vessels, hemorrhages and hemosiderosis in the left part and high cellularity with chronic inflammation in the right part, spindle-shaped cells in a loose myxoid stroma were observed in both parts of the tumor, consistent with the diagnosis of myxoma. His second operation for hepatic cancer was successfully performed following 1 month after the first operation. Surgical treatment should be considered for giant atrium tumor which has risk of life-threatening complications even if patients have another cancer.

[Aortoesophageal Fistula due to Aortic Aneurysm;Report of a Case].

A 77-year-old woman presented with general fatigue, was found to have anemia, and was referred to our hospital. Upper gastrointestinal endoscopy revealed a submucosal elevated lesion with a bleeding site and debris at the middle thoracic esophagus. Enhanced computed tomography demonstrated a thoracic aortic aneurysm compressing the esophagus. She was diagnosed with an aorto-esophageal fistula due to the thoracic aortic aneurysm. Graft replacement was performed under partial extracorporeal circulation. Because the perforation of the esophagus was small, omental flap transposition was performed without esophagectomy. Her post-operative course was uneventful, and she has been doing well without any infective episodes over 3 years after surgery.

[Corrected Transposition of the Great Arteries, Ventricular Septal Defect, Tricuspid Regurgitation and Pulmonary Hypertension Operated at Middle Age: Report of a Case].

A 45-year-old male with corrected transposition of great arteries and the ventricular septal defect (VSD) was considered to have no indication for the total repair because of severe pulmonary hypertension in his young age. He was suffered from heart failure with absence at the age of 44. Detail examinations revealed the severe tricuspid valve regurgitation with VSD. We reevaluated him for the operative indication by the aspect of pulmonary hypertension. His pulmonary vascular resistance decreased with the administration of 100% oxygen, and no pulmonary vascular obstructions were detected in the lung specimen. As a result, he underwent VSD patch closure and tricuspid valve replacement. His postoperative course was uneventful and he was discharged from our hospital at day 16 postoperatively. Our data suggested that reevaluation including lung biopsy should be important to determine operative indication for adult congenital heart disease.

[Acute type a aortic dissection operated in childhood; report of a case].

A 12-year-old boy without any previous history and risk factors of cardiovascular disease presented to the emergency room with persisting general fatigue, bilateral shoulder pain and facial pallor. He was diagnosed as acute type A aortic dissection with cardiac tamponade by ultrasonic cardiogram (UCG) and computed tomography (CT) imaging, and the emergency surgery was indicated. He underwent hemiarch replacement because his aorta diameter was quite small but grafting as a large vascular prosthesis as possible was necessary in consideration of the growth. His postoperative course was uneventful and good, and he was discharged from our hospital in day 21 postoperatively. Acute aortic dissection in childhood is very rare but life-threatening. We should consider the particularity of children and make early diagnosis and treatment appropriately.

[Left atrial posterior wall flap method for II a type of the isolated total anomalous pulmonary venous drainage].

We address the left atrial posterior wall flap (LAPF) method for the isolated total anomalous pulmonary venous drainage( TAPVD) II a. The postoperative pulmonary venous obstruction( PVO) is a serious complication and is not rare after repair of the isolated TAPVD II a by the conventional surgical techniques. The LAPF method contains superiorities to prevent PVO to the conventional surgical techniques by wider left atrium(LA) - pulmonary vein(PV) communication, less risk of turbulence and no need of a prosthetic patch or an autologous pericardial patch. Furthermore, from a hemodynamic point of view, it makes LA-PV communication a functional preloading chamber which leads the postoperative hemodynamics stable. So, we think that the LAPF method is able to be a standard operative technique for the isolated TAPVD II a.

[A case with Stanford type A acute aortic dissection that presented with consciousness disturbance and hemiparesis].

The patient was a 63-year-old female who had a past history of hypertension. She suddenly complained of agonizing pain and became comatose soon thereafter. Upon admission, she was in a state of shock, with upper airway obstruction and a coma. The pupils were dilated on both sides. The laboratory data showed that D-dimer was >80µg/mL. Brain CT scan and diffusion weighted MRI of the brain showed no abnormality. On brain 2D-CT angiography, the visualization of the right internal carotid artery and the right vertebral artery was poor. She eventually was able to nod her head in response to verbal commands, but her left extremities were completely hemiplegic. Cerebral angiography showed occlusion of the right vertebral artery at the branching point from the brachiocephalic artery, and was visualized in a retrograde fashion through the left vertebral artery. The brachiocephalic artery was severely stenotic in aortography. During angiography, she became able to speak and complained of back pain. Chest CT just after angiography showed a dissection in the aortic arch. Therefore, she was directed to the cardiovascular surgeon for immediate consultation. During the operation, the aortic dissection was revealed to be Stanford type A. Laceration of the intima was found in the ascending aorta and cardiac tamponade was also found. Total arch replacement was performed. The pathological examination showed that the arterial dissection occurred in the layer of elastic fiber, and the minimum arterial thickness of the medial layer was 0.2mm. The patient improved after the operation and her neurological deficits disappeared completely 13 days after operation. Brain and spinal MRI 15 days after the operation showed no abnormality.

[An approach to vacuum-assisted closure therapy using the S-B Vac].

Vacuum-assisted closure (VAC) therapy is increasingly applied for patients with wound dehiscence or mediastinitis caused by surgical site infection (SSI) after open-heart surgery. We have used wall suction for such cases in the past. But this method was an obstacle for improvement of the quality of life (QOL) of the patient. Since the S-B Vac is portable, this equipment may allow wound healing without decreasing QOL. Here, we report a case in which VAC therapy was performed using the S-B Vac.

Mitral valve motion after performing an edge-to-edge repair in an isolated swine heart.

OBJECTIVES: Mitral valve motion after performing an edge-to-edge repair is a major concern, but it has not yet been observed directly. Mitral valve motion was assessed by using a high-speed digital video camera and microsonometric analysis in an isolated swine heart, and any changes in the mitral valve area or the development of mitral stenosis symptoms were evaluated. METHODS: A temporary edge-to-edge repair model was created. The mitral valve motion was assessed by using a high-speed digital video camera, and the motion of the mitral annulus was measured by means of sonomicrometric analysis with or without performing edge-to-edge repair (n = 5). The left ventricular volumetric measurements were also measured with a conductance catheter. One cardiac cycle was divided into 4 phases: the mitral valve open phase, the isovolumic contraction phase, the aortic valve open phase, and the isovolumic relaxation phase. RESULTS: The mitral valve was divided into 2 orifices by using the edge-to-edge technique, and the mitral valve area decreased by approximately 30%. The ratio of mitral valve open phase significantly decreased (31.9% +/- 3.4% vs 41.4% +/- 3.7%, P = .04). There were no significant differences in the diameter and the changes of anteroposterior dimensions of the mitral annulus. The stroke volume and the peak positive and negative dp/dt values showed no obvious change, but dv/dt values increased slightly without significance after removing the edge-to-edge suture (118 +/- 25 vs 130 +/- 17 mL/s, P = .14). CONCLUSIONS: The mitral valve area decreased slightly; however, edge-to-edge repair did not create symptomatic mitral stenosis and showed no adverse affects on cardiac function.

Mitral valve motion assessed by high-speed video camera in isolated swine heart.

OBJECTIVE: We have recently reported our isolated and working swine heart model that examines the valve motion precisely by a high-speed digital video camera system. Using this modality, the present study aimed (1) to delineate the motion of the mitral leaflets, chords and annulus throughout the cardiac cycle, and (2) to elucidate the influence of alterations in loading conditions on leaflet excursion. METHODS: The valve motion of five isolated and working swine hearts was observed by an endoscope recording the images at 250 frames per second. Modified Krebs-Ringer solution was used as the sole perfusate. The images were obtained in hearts 30 min after reperfusion, changing the left atrial pressure as 4, 8, and 12 mmHg. RESULTS: The motion of the mitral valve in the vicinity of diastole was considered to be well understood by dividing the entire sequence into five stages: 'decoaptation,' 'E excursion,' 'diastasis,' 'A excursion,' and 'coaptation.' Initial separation occurred at both sides of the central tips of the leaflets. The leading edges always followed the mid-portion of the rough zone during opening and closing. The 'strut' second-order chords retained their tension throughout the cardiac cycle and played the role as rotary shafts of the other branching chords. The first-order chords lost their tension during opening, suggesting they mainly are involved in valve competence. Annular constriction occurred coincident with atrial contraction. An increase in preload made the isovolumic relaxation and contraction times shorter. The leaflets opened faster in the rapid-filling phase, whereas they required more time for opening and closing in the atrial-filling phase. CONCLUSIONS: The present study revealed the integrated movement of the mitral leaflets, chords and annulus, as well as the impact of altered preload.

Pseudoaneurysm from the mitral-aortic intervalvular fibrosa following endocarditis.

A rare case of a pseudoaneurysm from the mitral-aortic intervalvular fibrosa following bacterial endocarditis in a 17-year-old male is presented. Destructive infection secondarily involved the mitral-aortic intervalvular fibrosa. Perforation of this portion resulted in the formation of the pseudoaneurysm situated at the base of the left ventricle between the aorta and the left atrium. With echocardiography, computed topography, angiography, and magnetic resonance imaging (MRI), a pseudoaneurysm was diagnosed. MRI especially revealed detailed information and the extension of pseudoaneurysm. Our patient underwent resection of the pseudoaneurysm, reconstruction of left ventricular outflow with glutaraldehyde-preserved bovine pericardium, and replacement of the aortic valve. His postoperative course was uneventful. No recurrence of endocarditis was detected in the following year.