[Mitral regurgitation due to sole punched out lesion of the mitral anterior leaflet in infective endocarditis; report of a case].

Mitral regurgitation (MR) due to only punched out lesion is extremely rare in infective endocarditis. A 31-year-old male was admitted to our hospital due to unusual cause of MR. Echocardiography showed MR due to punched out lesion of the mitral anterior leaflet, which is extremely rare. A round shape punched out lesion (about 16 mm in size) was found intraoperatively in the anterior leaflet of the mitral valve. The surface around the punched out lesion was smooth, and the leaflet displayed good movability. Neither vegetation nor calcification was found. Punched out lesion was successfully closed with autologous pericardial patch and annuloplasty was performed.

[Comparative study of hypothermic circulatory arrest and normothermic distal perfusion for thoracoabdominal aortic aneurysm repair].

BACKGROUND: Hypothermic bypass with circulatory arrest for thoracoabdominal aortic aneurysm (TAAA) repair is employed for its protective effect on spinal cord function and because it avoids clamping the diseased aorta. However, organ dysfunction caused by reperfusion injury as well as bleeding tendencies due to deep hypothermia have been described. In this paper we compared the efficacies of the hypothermic and normothermic operations. METHODS: Between February 1996 and June 2000, 28 patients underwent thoracoabdominal aortic repair. Twenty-three patients were men, 5 were women, and the median age was 55.3 (range 23 to 75 years). Fourteen patients had aortic dissection, and 7 had Marfan syndrome. Fourteen patients required reconstruction of visceral arteries. Twelve patients underwent TAAA repair under deep hypothermic circulatory arrest (H group), and 15 under normothermic distal perfusion (N group), while 1 patient underwent a simple clamp procedure. Perioperative data and early outcomes were compared between groups. RESULTS: The overall 30-day mortality rate was 0%, but 3 patients (25.0%) in II group, and 1 patient (6.3%) in N group died during hospital stay. Operation time and bypass time were longer in H group than N group (operative time 793 min vs. 481 min (p < 0.05): cardiopulmonary bypass (CPB) time 255 min vs. 102 min (p < 0.05). Also, more intraoperative bleeding was found in H group than in N group (3,506 ml vs. 1,220 ml). Spinal cord neurologic deficit did not occur in either group. Respiratory failure occurred in 3 patients (25.0%) in H group and one (6.3%) in N group. Renal failure occurred in 3 (25.0%) in H group, and none in N group. CONCLUSION: Early and mid-term outcome of TAAA repair was almost satisfactory and without neurospiral complications. The deep hypothermic operation is more likely to induce postoperative respiratory and renal dysfunction than the normothermic operation. TAAA repair using deep hypothermic circulatory arrest should be limited to patients with TAAA involving the distal arch or a severely calcified aortic wall.

New technique for the outflow cannulation of right ventricular assist device.

Cannulating the outflow cannula of a right ventricular assist device (RVAD) through the main pulmonary artery is often troublesome because of extensive dissecting adhesion. We implanted RVADs using the new technique for outflow cannulating through the right pulmonary artery between the ascending aorta and the superior vena cava. With this technique, we needed only a little dissection and no cardiopulmonary bypass. This technique could make RVAD implantation simple, quick, and safe.

Serial hemodynamic study after aortic valve replacement in patients with narrow aortic roots.

BACKGROUND AND AIMS OF THE STUDY: The purpose of this study was to evaluate the hemodynamic performance after aortic valve replacement using different surgical options in small (19-mm diameter) annuli. METHODS: Postoperative hemodynamics were assessed in three groups according to the surgical method. A 19-mm St. Jude Medical (SJM) valve was used in nine patients (group A), a 19-mm SJM HP in nine patients (group B), and annular enlargement was performed in eight patients (group C). Echocardiography was performed and percent fraction shortening, peak pressure gradient, effective orifice area and left ventricular mass were measured. RESULTS: Postoperative peak systolic pressure gradient was decreased to 31.1+/-8.7 mmHg in group B, and to 22.3+/-11.7 mmHg in group C, but was 42.9+/-16.5 mmHg in group A (p <0.01). Percent fraction shortening and left ventricular mass index were improved in groups B and C, soon after surgery compared with group A (p <0.01). The effective orifice area significantly increased during exercise in group C, from 1.59 to 1.87 cm2 (p <0.01), but was not increased in groups A and B (N.S.). CONCLUSIONS: The small SJM HP provides a better hemodynamic performance than the standard 19 mm SJM. However, annular enlargement may be beneficial in patients with poor ejection fraction and severe ventricular hypertrophy.

Clinical assessment of prolonged myocardial preservation for patients with a severely dilated heart.

BACKGROUND: The purpose of this study was to compare the myocardial protective effect of histidine-tryptophan-potassium and glucose-insulin-potassium cardioplegic solutions in patients with a dilated heart (left ventricular diastolic diameter > 55 mm, left ventricular systolic diameter > 45 mm) associated with prolonged cross-clamp time (longer than 200 minutes). METHODS: We selected 20 patients with dilated hearts due to severe aortic regurgitation. Glucose-insulin-potassium cardioplegia was used in 11 patients and histidine-tryptophan-potassium cardioplegia was used in 9 patients. RESULTS: After operation, the cardiac index was significantly increased in the histidine-tryptophan-potassium group (p < 0.05). Postoperative percent fractional shortening was 13.4% +/- 3.1% in the glucose-insulin-potassium group and 23.6% +/- 2.6% in the histidine-tryptophan-potassium group (p < 0.05). Creatine kinase levels were significantly lower in the histidine-tryptophan-potassium group than that in the glucose-insulin-potassium group (p < 0.05). The incidence of ventricular arrhythmia (higher than Lown's grade 2) was lower in the histidine-tryptophan-potassium group. CONCLUSIONS: These data support the superiority of the histidine-tryptophan-potassium method over the glucose-insulin-potassium method for protection of the dilated heart during prolonged ischemia in open heart operations.

[A case of DVR with Nicks's procedure for active infective endocarditis with periannular abscess].

We successfully performed DVR with aortic annular reconstruction by Nick's procedure for a case of active infective endocarditis (IE) with perianular abscess. The patient was 26-year-old woman, who suffered from acute AR and MR due to active IE. At operation, a bicuspid aortic valve was noted with scattered vegetations. The periannular abscess extended from the aortic annulus to the anterior mitral leaflet on which there was a leaflet aneurysm. The complete debridement of infected lesions resulted in the defect of aortic annulus at the area of the aorto-mitral fibrous continuity. We reconstructed the aortic annulus by the equine pericardial patch and performed DVR, followed by the reconstruction of the aortic root by Nicks's procedure. After the operation the antibiotics had been administrated to the patient until CRP became completely negative. The patient was discharged from our hospital at 59 POD with no evidence of recurrence of IE. In such cases, we acknowledge the importance of as much complete debridement of infected lesions as possible and regard Nicks's procedure useful as one of the options for reconstruction of aortic root after debridement.

Surgical treatment of ischaemic valve disease.

Mitral valve regurgitation secondary to ischaemic heart disease carries a significant mortality even after open-heart surgery. In this study, 21 patients with mitral regurgitation associated with ischaemic heart disease were evaluated with respect to valvular pathology. Pathological examination of the mitral valve revealed chorda elongation or rupture in seven patients (group 1), papillary muscle dysfunction in 10 (group 2), and papillary muscle rupture in four (group 3). Significant preoperative characteristics in each group were subacute haemodynamic deterioration in group 1, chronic severe left ventricular failure in group 2, and a high incidence of acute renal failure associated with haemodynamic shock in group 3. Mitral valve plasty was performed in six patients and mitral valve replacement, using the St Jude Medical valve, in 15. Fourteen patients underwent mitral valve surgery combined with coronary artery bypass grafting. Mitral plasty was applied to the patients with low left ventricular function with mean(s.d.) fraction shortening of 19.2(6.2)% compared with 30.2(8.4)% in patients with mitral valve replacement. There were no operative deaths. Of four late deaths, two in group 1 resulted from infection and myocardial infarction, respectively and one in group 2 resulted from arrhythmia. One patient in group 3 died from renal failure. It is suggested that incorporation of these therapeutic concepts may lead to satisfactory results in the surgical treatment of ischaemic mitral regurgitation.

Double balloon catheter for concomitant augmentation of abdominal organ perfusion during intraaortic balloon counterpulsation.

A newly devised double balloon catheter to augment abdominal organ perfusion concomitant with original cardiac assist during intraaortic balloon counterpulsation provided satisfactory hemodynamics and urinary output around cardiac surgical procedures in 2 patients with coronary artery disease. Some optional advantages in clinical application and problems arising in the catheter design which need to be investigated are discussed.

Combined aortic and mitral valve replacement in an adult with mucopolysaccharidosis (Maroteaux-Lamy syndrome).

A 41-year-old man with aortic stenosis, mitral stenosis, and tricuspid regurgitation due to Maroteaux-Lamy syndrome underwent aortic and mitral valve replacement with tricuspid annuloplasty. The annular diameter of the aortic and mitral valves was extremely small. The valve prostheses were 19 mm in diameter in the aortic position and 25 mm in the mitral position. Histologically, the valves showed thickening and hyalinization of the collagen fibers, and the presence of foamy cells that contained a large quantity of pure acid mucopolysaccharide. On an echocardiographic examination performed 2 years after the surgery, the peak systolic gradient of the trans-aortic valve was 18 mmHg at rest, and 26 mmHg during exercise. Careful observation of the residual pressure gradient will be needed. The patient's present New York Heart Association (NYHA) status is grade I and he has returned to work.

The role of leukocyte depletion in reducing injury to myocardium and lung during cardiopulmonary bypass.

Activated leukocytes and oxygen free radicals have been implicated in the pathogenesis of heart and lung injury after reperfusion and during cardiopulmonary bypass. This study was designed to determine whether leukocyte depletion prevents injury to the heart and lung during cardiopulmonary bypass. Twenty-eight open heart surgeries were performed in this study. In Group F, leukocyte depletion was performed with an LG-6 arterial line filter after aortic declamp (n = 14). Leukocyte depletion was not performed during cardiopulmonary bypass in Group C (n = 14). Thereafter, cardiac and lung function were assessed in the 24 hr after reperfusion. The total catecholamine dose used for 24 hr after reperfusion (r) was 61.9 +/- 13.4 in Group C and 43.9 +/- 19.2 in Group F (p < 0.05). CK-MB at 3 and 6 hr after reperfusion was 65.9 +/- 13.5 and 64.8 +/- 15.8 in Group C and 45 +/- 11.8 and 38 +/- 10.8 in Group F, respectively (p < 0.05). The pulmonary index after reperfusion at 3 and 6 hr was 1.7 +/- 0.5 and 1.3 +/- 0.4 in Group C and 0.7 +/- 0.3 and 0.6 +/- 0.4 in Group F, respectively (p < 0.05). There was significantly better preserved lung function in Group F. In conclusion, leukocyte depletion was significantly effective in preserving heart and lung function during cardiopulmonary bypass.

[Preservation of fresh homograft using TC199 solution in rat].

The surgical replacement of human vessels using fresh allografts (homograft) has been reported as useful means. Nevertheless, little is known about preservation effect and immunological consequences using TC199 solution. In this study, defined inbred strains of rats were used. The aorta was extracted from Buffalo rats and preserved for 1, 2, and 3 weeks in TC199 solution at 4 degrees C. The preserved graft was then implanted into the Buffalo rats heterotopically, in the abdominal aorta, in the autotransplant group (AUTO) and into the Lewis rat in the allotransplant group (ALLO). The graft patency and histology including immunohistochemical stain (IgG, IgM, and C3 complement) were assessed at 2 weeks after transplantation. In AUTO, the patency was 100% with grafts 1 and 2 weeks' preservation, and 80% with 3 weeks' preservation. In the ALLO, patency was 100% with grafts with one week's preservation, 80% in those with 2 weeks' preservation and 0% those with in 3 weeks' preservation. Histology revealed that fibroblasts and endothelial cells were significantly deteriorated in 3 weeks' preservation in auto transplantation, however, they were well-maintained in 2 weeks' preservation. In the allo-transplantation group, histological deterioration began after 2 weeks preservation. Immunohistochemical staining showed significant deposits of IgG, IgM and C3 in ALLO. Significant infiltration of antibodies was seen in deteriorated tissue due to prolongation of the preservation periods. These results suggested that freshly preserved allograft was antigenic and 2 weeks preservation using TC199 solution was possible in the rat model.

[Surgical treatment of ischemic mitral regurgitation].

Mitral regurgitation secondary to ischemic heart disease carries a significant mortality even after emergent open heart surgery. We report on 16 patients with mitral regurgitation associated with ischemic heart disease. The pathological findings were chorda elongation and papillary muscle dysfunction (PMD group) in 12 patients, and papillary muscle rupture (PR group in 4 patients. Preoperative characteristics were severe left ventricular failure in PMD group and high incidence of renal failure, in associated with high age in PR group. In PMD group, mitral plasty was performed in 10 patients out of 12 patients. In PR group all patients underwent mitral valve replacement. Thirteen patients underwent mitral surgery combined with coronary artery bypass grafting. No operative death was seen, one hospital death and 3 late deaths occurred. Three late deaths were seen in PMD group due to sudden death in 2 cases and arrhythmia in 1 case. One hospital death in PR group was due to multi-organ failure. We suggested incorporating these therapeutic concepts may introduce satisfactory results in surgical treatment for ischemic mitral regurgitation.

[Clinical experience of autotransfusion of shed mediastinal blood using a new device].

Autotransfusion of shed mediastinal blood is expected to be adopted as a technique to reduce transfusion thus preventing various complications such as hepatitis, AIDS, and GVHD. We report the usefulness and problems of a new device-Solcotrans Plus, which only requires connection to wall suction. This device consists of three parts: suction, reservoir bag, and filter for autoinfusion. After setting the suction and reservoir bag primed with anticoagulant, ACD or heparin, and connecting the unit to a wall suction, we performed autotransfusion of shed blood through the filtration component in ICU after operation. Postoperative hematological and biochemical examinations revealed no complications or adverse effects of autotransfusion. This device is available, simple to handle, and is useful for returning shed blood. We believe that this device will be effective for non-blood open heart surgery or reduction of transfusion.

[Pre and postoperative management of a patient after cardiac transplantation performed in UCLA].

The patient with dilated cardiomyopathy (NYHA grade 4) underwent cardiac transplantation at University of California, Los Angeles. Postoperative management in our institute consisted 1) cardiac biopsy, 2) measurement of blood concentration of cyclosporin, 3) serum anti-CMV titer, 3) echo cardiography, 4) counts of lymphocyte subsets. Cardiac rejection (Ib) was observed 2 months after transplantation and steroid pulse therapy (methylprednisone 500 mg/day) was performed for 3 days. Blood concentration of cyclosporin was decreased with administration of probucol and increased with diltiazem. Presently, the patient is stable and back to normal work.

[Rescue effect of 15-deoxyspergualin for acute rejection on heart transplantation--using a rat model].

15-Deoxyspergualin (DSG) attracts a lot of attention as an immunosuppressive drug which has less side effects these days. In the present study, we researched the rescue effect of DSG for acute rejection on heart transplantation (HTX) by using rat models. We performed 40 heterotopic heart transplantation models. We injected them DSG (group A: 5 mg/kg/day, group B: 10 mg/kg/day) intravenously through 3 days, starting from the 3rd day the 4th day, and the 5th day after HTX. Our previous study showed the pathology on the 3rd day after HTX corresponded to mild rejection, the 4th day to moderate rejection, and the 5th day to severe rejection. One day after the injection was completed, the recipients were sacrificed. The rescue effect was histopathologically assessed by H-E stain, and the action mechanism of DSG was considered by immunohistochemical stain using monoclonal antibodies, which were against CD4 positive cells, CD8 positive cells, and macrophages. In result, the rescue effect of DSG was significant in all groups, in comparison with controls, which had no immunosuppression. And the rescue effect of group B was superior to group A. We also found using a immunohistochemical technique, that DSG inhibited the accumulation of CD4 and CD8 positive cells. We concluded the rescue effect of DSG for acute rejection on HTX was significant, especially in 10 mg/kg/day even in the severe rejection. And the suppression of helper and cytotoxic T cells accumulation might be one of the action mechanisms of DSG.