[Posterior Mitral Leaflet Patch Augmentation with Autologous Pericardium in a Neurofibromatosis Typeâ Patient:Report of a Case].

The patient was a 61-year-old man with neurofibromatosis typeⅠ, who had several papules in a whole body. Medical history included atrial fibrillation and cerebral embolism. Transthoracic and transesophageal echocardiogram revealed severe mitral valve regurgitation and tricuspid valve regurgitation due to annular dilation with atrial enlargement, tethering of the posterior mitral leaflet, the anterior mitral leaflet prolapse with chordal rupture. Mitral valve repair and tricuspid annuloplasty, maze procedure were performed via median sternotomy. Mitral valve repair was performed by chorda reconstruction with artificial chordae to A2, patch-augmentation of the posterior leaflet with 0.6% glutaraldehyde-treated autologous pericardial patch and ring annuloplasty. There was no abnormal bleeding during surgery, and surgical site infection was not observed. Postoperative echocardiogram showed the augmented posterior leaflet created a deep and tightly uniform coaptation to the anterior leaflet and mitral regurgitation was well controlled.

Open Surgical Repair for a Giant Common Hepatic Artery Aneurysm with Difficulty in Proximal Arterial Clamping: A Case Report.

Hepatic artery aneurysm has been considered as a rare, life-threatening disease. In this study, we report on a patient requiring surgical treatment for a giant hepatic artery aneurysm by aneurysmectomy without revascularization. A 70-year-old woman who complained of epigastric pain was referred to our hospital. Enhanced computed tomography scan has revealed a giant (11×9 cm) common hepatic artery aneurysm. She then underwent emergency surgery; the intra-aortic balloon occlusion technique was applied in order to control the blood inflow into the aneurysm. The aneurysm was then incised, and direct closure of the inflow and outflow orifices was performed safely without evidence of ischemic change in the liver.

[Structural Deterioration of a Bovine Pericardial Valve in a Tricuspid Position 14 Years Postoperatively;Report of a Case].

Although nonstructural dysfunction of a bioprosthesis caused by pannus formation or native valve attachment has been well described, structural valve deterioration( SVD) caused by calcification or tear of a bioprosthesis, especially a bovine pericardial valve, is very rare in the tricuspid position. We report a case of redo tricuspid valve surgery for SVD 14 years after tricuspid valve replacement( TVR) using a Carpentier-Edwards Perimount (CEP) pericardial valve. A 71-year-old woman was referred to our hospital because of exertional dyspnea and pre-syncope. She had undergone mitral valve replacement with a St. Jude Medical mechanical valve and TVR with a CEP pericardial valve 14 years previously. Transthoracic echocardiography revealed tricuspid valve stenosis with a mean trans-tricuspid valve pressure gradient (TVPG) of 7.3 mmHg. Redo TVR using a CEP Magna Mitral Ease valve was performed under cardiac arrest. Severe calcification was observed on the ventricular side of the leaflets of the explanted valve. The mean TVPG decreased to 3.2 mmHg after surgery, and the patient's postoperative course was uneventful.

Coronary Arteriovenous Fistula in Continuity With the Aortic Arch.

Coronary arteriovenous fistula in continuity with the aortic arch by abnormal vessels running along the surface of the pulmonary artery is rare. We describe 2 patients with this rare and unique arteriovenous network and discuss the issue of diagnosis and treatment with a review of the literature.

[Three Mitral Valve Operations in a Patient with Trousseau Syndrome and Nonbacterial Thrombotic Endocarditis Caused by Ovarian Cancer].

A 52-year-old woman was admitted to our hospital for acute right hemi-paresis, left homonymous hemianopia, and fever. Magnetic resonance imaging of the brain showed multiple cerebral infarctions and transesophageal echocardiography (TEE) revealed a vegetation on the posterior leaflet of her mitral valve. Mitral valve repair was performed under a diagnosis of infective endocarditis (IE). Further multiple cerebral infarctions occurred on the 11th postoperative day, resulting in left hemiplegia and dysarthria. TEE revealed vegetations on her mitral valve and mitral valve replacement (MVR) was performed. Microscopic examination of the resected valve showed mild lymphocytic infiltration, but no bacterial or fungal organisms were detected. On the 66th day after the initial surgery, she developed deep vein thrombosis and acute pulmonary embolism. Abdominal computed tomography showed a huge ovarian tumor, and TEE demonstrated vegetations on the left atrial wall, the aortic valve, and the mechanical valve immobilizing one of the leaflets. The patient was finally diagnosed as having Trousseau syndrome caused by an ovarian tumor and non-bacterial thrombotic endocarditis( NBTE). Three months after the initial operation, redo MVR was performed and aortic valve vegetations were removed. Four days later, the ovarian cancer was resected. Her postoperative course was uneventful and she was discharged on foot on the 143rd day after the initial operation. NBTE caused by malignancy is rare but must be considered when managing endocarditis.

[Bridge to recovery with ventricular assist device support for eosinophilic myocarditis].

A 39-year-old man initially presented with cough, fever, and shortness of breath. His symptom got worse gradually, and he was admitted to a nearby hospital. Echocardiography revealed a dilated left ventricle and severe left ventricular dysfunction. Despite inotropic and intra-aortic balloon pumping (IABP) support, the patient developed cardiogenic shock with fever of unknown origin, followed by multi-organ failure. A left-ventricular assist device (LVAD) was implanted. Pathologic evaluation showed an extensive eosinophil-rich inflammatory infiltrate, and consistent with the diagnosis of eosinophilic myocarditis. After high-dose steroid administration, the cardiac function improved and explantation of the LVAD was successfully performed. The patient was discharged and remains well at the 24-month follow-up.

Effect of external counterpulsation on cardiac work following cardiac surgery: implications of the mechanism responsible for clinical benefits.

BACKGROUND: External counterpulsation (ECP) has been recognized as a non-invasive treatment for chronic refractory angina or heart failure. However, the mechanisms responsible for the clinical benefits of ECP therapy remain elusive. Moreover, the clinical significance of ECP therapy for postoperative patients has not been established yet. METHODS: Six adult patients received ECP therapy for 60 min under pulmonary artery catheter monitoring after cardiac surgery. Hemodynamic data were obtained before ECP therapy (pre-ECP), 20 min after ECP was commenced (20-min-ECP), 40 min after ECP was commenced (40-min-ECP), and after ECP therapy (post-ECP). RESULTS: The mean right atrial pressure (pre-ECP: 9 ± 4 mmHg; 20-min-ECP: 12 ± 5 mmHg; 40-min-ECP: 12 ± 4 mmHg; and post-ECP: 9 ± 4 mmHg), pulmonary wedge pressure (16 ± 6 mmHg, 20 ± 7 mmHg, 20 ± 7 mmHg, and 17 ± 7 mmHg, respectively), cardiac index (2.4 ± 0.4 l/min/m(2), 2.8 ± 0.6 l/min/m(2), 2.7 ± 0.5 l/min/m(2), and 2.5 ± 0.4 l/min/m(2), respectively), cardiac work index (2.5 ± 0.4 kgm/m(2), 3.3 ± 0.8 kgm/m(2), 3.1 ± 0.8 kgm/m(2), and 2.6 ± 0.5 kgm/m(2), respectively), and left ventricular stroke work index (32 ± 7 gm/m(2), 41 ± 12 gm/m(2), 39 ± 12 gm/m(2), and 33 ± 8 gm/m(2), respectively) significantly (p<0.05) increased after ECP was commenced (pre-ECP vs. 20-min-ECP) and decreased after ECP was discontinued (40-min-ECP vs. post-ECP). Significant (p<0.001) diastolic augmentation (20-min-ECP: 24 ± 6%, 40-min-ECP: 23 ± 5%) and systolic unloading (3 ± 1%, and 3 ± 1%, respectively) were obtained. No clinical adverse effects were observed. CONCLUSIONS: ECP increases venous return, cardiac output, and cardiac work in addition to diastolic augmentation and systolic unloading. These actions may play important roles in the clinical benefits of ECP therapy. Our data also suggest that ECP is beneficial for patients undergoing cardiac surgery.

Experience of a patient with an extracorporeal ventricular assist system who participated in a sleepover program.

A 19-year-old woman suffered fulminant myocarditis owing to a mycoplasma infection and was inserted with an intra-aortic balloon pump and a percutaneous cardiopulmonary support. Antibiotics and gamma globulin were administered, however, the patient's cardiac function did not recover, and the TOYOBO ventricular assist device (VAD) was implanted. She had rehabilitation training such as maintaining a standing position at the bedside and walking in the hospital, and a hospital outing program to a family restaurant was conducted two times with the VAD. The patient wished to attend the coming-of-age ceremony in Tachikawa city, which is 3 h away from our hospital by car. Therefore, we planned the program including a night stay at her home. The patient and her family fully understood the risks and wished to participate in the sleepover program. In preparing for the sleepover, the patient and her family learned to operate the VAD, and she was able to move to the lavatory and through the house with the help of only her family. A physician and a clinical engineer stayed at her house for infusion of antibiotics and management of sudden changes. There was no adverse event. In Japan, the community support of patients with VAD is not yet established, and we hope that our experience becomes a help to support return to society for patients with VAD.

[The survey on the work environment of young cardiovascular surgeons].

We carried out the questionnaire of the working environment of young cardiovascular trainees, which are equal and less than ten years after graduation from medical school. We asked 261 surgeons for questionnaire on direct mail and 76 (29.1%) replied. Most of them thought they were working in poor environment. 47 surgeons (61.3%) were not satisfied with their current works. Main reasons were less chance of surgical cases as primary surgeons and lots of duties and paper works which were not related to operations and pre-and post-operative management. Primary thing that we have to do, would be to construct the system, which the medical clerk and physician's assistant share duties and reduce the labor burden on doctors. Many young surgeons expect to built up their social status as cardiovascular specialist. We considered that the improvement of working circumstances with establishing a system of physician assistant, drastic practice curriculums, would be necessary, before the discussion to put together cardiovascular institutions.

[Support for temporary homecoming of a patient with ventricular assist device].

A 19-year-old woman suffered from fulminant myocarditis by Mycoplasma infection, and intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were initiated. As the cardiac function was not recovered, the ventricular assist device (VAS) was implanted. Rehabilitation training was started such as maintaining standing position at the bedside, and walking. The preparatory training program for homecoming was conducted twice with VAS. She strongly hoped for participation of coming-of-age ceremony in Tachikawa City that is 3 hours' drive from our hospital. The patient stayed 1 night at home with a doctor and a medical engineer. There was no adverse event. In Japan, the community support of patients with VAS is not yet established and we hope that our experience will be of some help in supporting the homecoming of patients with VAS.

Adventitial cystic disease of the femoral vein.

Adventitial cystic disease of the blood vessel wall is a rare disease. It occurs most commonly in arteries and very rarely in veins (Levien and Benn, J. Vasc. Surg. 1998;28:193-205). We report the case of a 28-year-old man with severe adventitial cystic disease of the femoral vein who underwent a resection of the cystic wall.

Effects of rabeprazole or famotidine during cardiac surgery on perioperative gastric and esophageal pH readings.

OBJECTIVES: Upper gastrointestinal bleeding, particularly from a stress-induced duodenal ulcer, is an extremely important perioperative complication in cardiovascular surgery. METHODS: In the present study, 33 patients undergoing elective open heart surgery between July 2000 and February 2001 were allocated to either a famotidine (FAM) or rabeprazole (RPZ) group to examine the perioperative gastric and esophageal pH readings, in conjunction with an investigation into the effect of infection with Helicobacter pylori (HP). RESULTS: Postoperative upper gastrointestinal bleeding did not occur in either group, and the intraoperative and postoperative mean gastric pH readings, as well as the holding time pH>6, suggested sufficient acid suppression by either drug. Gastric acid secretion was less strongly suppressed in HP-negative patients in the FAM group, but was unaffected by HP infection status in the RPZ group. CONCLUSION: The FAM group and RPZ group revealed a sufficient effect of gastric acid suppression. It was indicated that FAM had an insufficient effect of gastric acid suppression for HP-negative patients.

[Rupture of a chronic dissecting giant aneurysm into the pulmonary artery; report of a case].

Aortopulmonary fistula is an extremely rare complication of aortic dissection. We report a case of a chronic dissecting giant aneurysm with an aortopulmonary fistula. A 78-year-old woman experienced sudden onset chest pain and oppression. Chest X-ray showed ascending aortic and left ventricular enlargement and pulmonary congestion. Computed tomography (CT) confirmed the 100 mm ascending aortic aneurysm with dissection and aortopulmonary fistula. Operative repair was performed under profound hypothermic circulatory arrest with selective cerebral perfusion. The proximal and distal end were obliterated using a gelatin-resorcin-formaldehyde tissue glue and reinforced with a Teflon felt circumferential strip. The ascending aorta was replaced by a 30 mm coated Dacron vascular graft and the aortopulmonary fistula was closed with pledgeted vertical mattress suture. Postoperative CT showed a normally functioning vascular implant without any sign of aortopulmonary shunt or pulmonary artery stenosis.

Revascularization using satellite vein after radial artery harvested for coronary artery bypass grafting.

The radial artery has been increasingly used for coronary artery bypass grafting and has excellent long-term patency rates. Hand claudication is one of the adverse effects after radial artery harvest. We reconstructed a radial artery using the satellite vein to prevent hand claudication. Pulsating blood flow at 35 cm/sec was evaluated using color Doppler echocardiography three months after surgery. This method makes it possible to use a radial artery in patients with a positive Allen test.

Venous drainage method for cardiopulmonary bypass in single-access minimally invasive cardiac surgery: siphon and vacuum-assisted drainage.

Vacuum-assisted venous drainage (VAVD) can facilitate venous drainage in single-access minimally invasive cardiac surgery (SAMICS). We retrospectively examined the use of VAVD in SAMICS in our hospital for this report. VAVD has been performed according to a VAVD protocol since 2000. Data from the 110 patients who underwent SAMICS in our institute from January 2000 to June 2002 were reviewed retrospectively. The total negative pressure was maintained at no greater than -90 mmHg. Indications for use of VAVD (protocol) were: insufficient venous return by siphon drainage alone, persistent elevation of the central venous pressure (CVP), and, insufficient venous drainage in the operative field. Of 110 patients, 97 (88.2%) underwent VAVD. The body surface area was significantly smaller in the group that did not require VAVD (the non-VAVD group) than in the group that did (VAVD group) (VAVD group versus non-VAVD group: 1.586 +/- 0.175 versus 1.408 +/- 0.153 m(2), P < 0.001). Other factors such as cardiopulmonary bypass time, aortic cross-clamp time, postoperative maximum lactate dehydrogenase, postoperative maximum creatinine, postoperative maximum blood urea nitrogen were similar in the two groups. VAVD is necessary in SAMICS except for small patients. A VAVD total negative pressure of -90 mmHg did not hinder operative procedures or cause clinical problems.

Kommerell's diverticular rupture complicated by aberrant left subclavian artery and right aortic arch successfully treated surgically.

We report a rare case of a rupture in Kommerell's diverticulum in a 73-year-old woman with Edwards IIIB aberrant left subclavian artery (A-LSA) and right aortic arch. This case was further complicated by an inferior vena cava defect. We performed an emergency operation through a right posterolateral approach. The descending aorta was replaced and the Kommerell's diverticulum was excised, followed by A-LSA reconstruction, performed under deep hypothermia with selective cerebral perfusion. We believe the prognosis was excellent.