A stepwise aortic clamp procedure to treat porcelain aorta associated with aortic valve stenosis and hemodialysis.

A 62-year-old man was referred for an aortic-valve surgery because of severe aortic stenosis. Thirty years ago, he had undergone a mitral valve commissurotomy and after 9 years, the valve had been replaced by a mechanical valve. He had been undergoing hemodialysis for the past 8 years. A computed tomographic (CT) scan of the chest and abdomen showed a dense circumferential calcification in the wall of the entire thoracic and abdominal aorta, pulmonary artery, and left and right atrium. A conventional aortic-valve replacement was performed. To avoid an embolic event, a "stepwise aortic clamp" procedure was attempted and involved the following: (1) brief circulatory arrest and aortotomy during moderate hypothermia; (2) balloon occlusion at the ascending aorta during low-flow cardiopulmonary bypass (CPB); (3) endoarterectomy by using an ultrasonic surgical aspirator to enable aortic cross-clamping; and (4) a cross-clamp reinforced with felt and full-flow CPB. The patient recovered without any thromboembolic events. Using this procedure to treat a porcelain aorta seemed to reduce the time limit and reduced the risk of brain injury during cardiac surgery.

Off-pump multilayered sutureless repair for a left ventricular blowout rupture caused by myocardial infarction in the second diagonal branch territory.

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

A case report of pulmonary thromboendarterectomy for chronic thromboembolism in a patient with protein C deficiency.

The patient was a 41-year-old female with chronic thromboembolism. She was admitted to an affiliated hospital with exertional dyspnea, leg swelling, and hemoptysis, and she was treated medically with tissue plasminogen activator and warfarin therapy. When transferred to our hospital, she was oxygen-dependent with severe dyspnea. A pulmonary arteriogram showed occlusion and stenosis of the pulmonary arteries. Cardiac catheterization revealed marked pulmonary hypertension. The lung perfusion scintigram showedmultiple defects in the right and left lungs. Preoperative laboratory data showed a markedly decreased protein C antigen level. Magnetic resonance angiography showed that a myoma uteri compressed the pelvic vein and that she had deep vein occlusion of the left leg. After the administration of an epoprostenol infusion and the insertion of an inferior vena cava filter, she underwent an operation. Under deep hypothermia, the bilateral pulmonary artery was opened and an endarterectomy was performed during intermittent circulatory arrest. After surgery, her pulmonary vascular resistance was in the normal range. Her New York Heart Association functional classification changed from class IV to class I. She has been in good condition for 7 years since the surgery.

Occupational true aneurysm of the ulnar artery: a case report of hypothenar hammer syndrome.

A 32-year-old male patient was admitted to the hospital with a pulsing mass of the right palm. He was an electrical construction engineer who frequently used a screwdriver. Computed tomography (CT) examination revealed a 22- × 30-mm saccular aneurysm of the right ulnar artery. The ulnar artery aneurysm was resected, and we could perform direct anastomosis of the ulnar artery. The dilated true aneurysm was compatible with a traumatic origin. A postoperative enhanced CT examination showed smooth reconstruction of the palmar arch. An occupational true aneurysm of the ulnar artery could be treated by resection and direct anastomosis.

Surgical repair of postinfarction ventricular septal defects-2013 update.

Treatment for postinfarction ventricular septal defect has been improving for several decades. Aggressive resection of the infarcted myocardium (infarctectomy and closure technique) and preserving infarcted myocardium (infarct exclusion technique) have been technically modified. Recent improvement includes use of surgical glue, using an additional patch for infarct exclusion, septal exclusion, sandwich technique via right or left ventricular approach, and endovascular repair. This field still has room for cardiac surgeons to improve surgical strategy and technique.

Midterm results of the "sandwich technique" via a right ventricle incision to repair post-infarction ventricular septal defect.

BACKGROUND: Residual shunting and mortality are problems associated with current surgical repair techniques for post-infarction ventricular septal defects. METHODS: We describe the mid-term results of the "sandwich technique" to repair a post-infarction ventricular septal defect (VSD), performed via a right ventricle incision. Application of direct ultrasonography to the right ventricular wall enables a surgeon to visualize the region, perform an appropriate incision into the right ventricle, and perform a trabecula resection. One patch is placed on the left ventricular (LV) side and the other on the right ventricular (RV) side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches. RESULTS: We had seven consecutive patients. The sandwich technique resulted in geometric preservation of the LV shape. There were no significant leaks, no mortality within a thirty-day postoperative period, and no bleeding problems. Hospital mortality was 14.3% (1/7 cases). Late survival longer than a year was obtained in five cases (71%). The longest patient survival time was nine years. No tissue degeneration was noted. CONCLUSION: This technique may be useful for repairing a post-infarction VSD.

The "loop with anchor" technique to repair mitral valve prolapse.

The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure.

Coronary malperfusion due to flap suffocation after acute type A dissection surgery.

A 24-year-old man presented with chest pain. He was diagnosed as having a type A acute aortic dissection and an annulo-aortic aneurysm. After emergency surgery for an aortic root replacement, his electrocardiogram showed ST-segment depression and T-wave inversion. Echocardiography showed asynergy of the left ventricle without coronary ostial pathology. Heart catheterization revealed no coronary stenosis, but the true lumen of the residual ascending aorta had extreme diastolic narrowing due to flap suffocation. This resulted in coronary malperfusion. The pullback pressure curve confirmed the mechanism. The patient underwent a surgical re-intervention for a total arch repair, which diminished the coronary malperfusion. At a follow-up appointment four years and four months later, the patient was doing well.

Papillary muscle approximation and relocation with a loop technique for mitral complex repair.

Undersized mitral annuloplasty alone is not always sufficient to repair functional mitral regurgitation resulting from left ventricular enlargement; the repair requires a three-dimensional approach to the mitral complex. We introduce a surgical procedure that combines papillary muscle approximation to correct lateral shift and papillary muscle relocation using the loop technique to correct the apical shift with accuracy and technical ease.

In vitro study of the optimum volume ratio of activator to adhesive in gelatin-resorcin-formalin glue.

OBJECTIVE: Excessive use of activator (formaldehyde + glutaraldehyde) may cause late complications after use of gelatin-resorcin-formalin (GRF) glue during surgery. The goal of the study was to define the appropriate ratio of activator to adhesive and to establish an approach for accurate control of this ratio. METHODS: The relation between adhesive force and the activator/adhesive ratio was studied by attaching two sheets of equine pericardium using GRF glue, with ratios from 1: 50 to 1: 2. The amount of activator was measured per drip from the needle in the GRF glue kit and other needles (27, 25, 23, 22, and 21 gauge). RESULTS: The adhesive force was about 400 gram-weight (gw) for activator/adhesive ratios from 1: 50 to 1: 20. This force showed a significant increase to 1317 ± 462 gw for a ratio of 1: 10 compared to the force at a ratio 1: 20 (P = 0.0069) but did not increase significantly for ratios above 1: 10. The activator volume was 12.5 µl in one drip from the needle in the GRF glue kit and 4.3 µl in one drip from the 27-gauge needle. Therefore, the 27-gauge needle is suitable for measuring the activator volume. CONCLUSION: In vitro, an activator at a ratio of one-tenth the volume of the adhesive provides approximately maximum force; any more activator is residual and potentially harmful. Measurement of the activator volume using a 27-gauge needle and the adhesive volume using a syringe is recommended to control the ratio accurately.

Pyogenic vertebral osteomyelitis after surgery for rupture of the aortic arch.

Vertebral osteomyelitis is a very rare and intractable complication after vascular surgery. We describe a case of pyogenic vertebral osteomyelitis induced by methicillin-resistant Staphylococcus Aureus sepsis following surgery for traumatic rupture of the aortic arch, successfully managed with long-term antibiotic therapy for 75 weeks.

Apoptosis and angiogenesis are induced in the unstable coronary atherosclerotic plaque.

OBJECTIVE: Apoptosis and angiogenesis may be involved in the pathogenesis of atherosclerosis and plaque destabilization. In this study, we investigated if apoptosis and angiogenesis were induced in the unstable human coronary atherosclerotic plaque compared to stable atherosclerotic plaque. METHODS: Atherosclerotic plaques from patients with stable (n = 9) and unstable angina (n = 13) were obtained by directional coronary atherectomy performed during percutaneous transluminal coronary angioplasty. Apoptosis was detected by terminal deoxynucleotidyl transferase end labelling (TUNEL), as well as by immunostaining for caspase 3, Bax and Bcl-2. Neovascularization was determined by immunostaining for the endothelial cell-specific CD31, vascular endothelial growth factor (VEGF-A), angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), hypoxia inducible factor-1alpha (HIF-alpha), and the sections were quantified blindly. RESULTS: The apoptotic nuclei were more frequently found in the unstable coronary atherosclerotic plaques. When the number of apoptotic cells was quantified, an increased apoptotic index was found in the unstable plaques (P = 0.04). The positive staining for caspase-3 was increased in the unstable plaques (P = 0.0008), while no difference in either Bax or Bcl-2 was found between groups. Neovascularization, as evidenced by lumens surrounded by a CD31 positive endothelial layer, was more frequently present in the plaques from patients with unstable angina (P = 0.04). The number of cells with positive staining for VEGF-A was increased in unstable plaques (P = 0.005). No difference of Ang I, Ang II, HIF1-alpha was found between groups. CONCLUSIONS: In unstable human coronary plaques, apoptosis probably involving caspase 3 was found. The plaques had an increased neovascularization, probably induced by VEGF-A. These factors may contribute to explaining plaque destabilization and intraplaque haemorrhage.

Effect of modified ultrafiltration on inflammatory mediators, coagulation factors, and other proteins in blood after an extracorporeal circuit.

Modified ultrafiltration (MUF) is a technique able to remove the excess body fluid and inflammatory mediators associated with the use of a cardiopulmonary bypass (CPB). It has been shown to reduce morbidity after cardiac operations in children. Application of MUF after adult cardiac operations has also been suggested being associated with a lower prevalence of early morbidity. However, the relationship between the concentration of mediators in the blood and postoperative morbidity remains yet to be proved. In this study, changes of various chemical mediators in the filtrate and blood before and after MUF have been evaluated in adult patients. Significant reductions of blood levels of inflammatory cytokines were not observed after MUF. On the other hand, MUF significantly elevated hematocrit, number of red cells, concentrations of albumine, coagulation Factor VII and X, platelet factor (PF)-4, and antithrombin (AT-) III.