Successful hybrid repair of a giant coronary artery aneurysm after previous coronary artery bypass grafting.

A 64-year-old woman had undergone coronary artery bypass grafting (CABG) for right coronary occlusion and the Dor procedure for a left ventricular apex aneurysm 10 years previously. A follow-up computed tomography scan showed the evolution of a giant coronary artery aneurysm (CAA) located on the proximal left circumflex artery (CX). It also revealed a previous saphenous vein graft (SVG) that was patent and located on the midline. Surgical exclusion was regarded as invasive, and isolated percutaneous intervention was unsuitable for a wide-necked CAA. Thus, a hybrid approach was planned. First, CABG (SVG-CX) via left thoracotomy was performed. Following the surgery, stent-assisted coil embolization was performed. A coronary angiogram revealed complete CAA exclusion. Learning objective: Many authors have reported successful repair for coronary artery aneurysm (CAA) with a percutaneous approach or surgery. Although there is no consensus for giant CAA repair, surgical repair including resection, ligation, and coronary artery bypass grafting have been recommended in previous reports. However, every decision should be tailored to suit each condition. In this case with the history of previous cardiovascular surgery, our hybrid approach was thought to be less invasive and feasible than isolated surgical or percutaneous repair.

A case of cardiac calcified amorphous tumor complicated with acute myocardial infarction.

An 80-year-old woman with a history of eosinophilic granulomatosis with polyangiitis, cardiac hypertrophy, and diabetes called for an ambulance after developing chest pain. She was diagnosed with acute myocardial infarction (AMI), and coronary angiography revealed occlusion of the right coronary artery. Coronary aspiration was performed, and coronary aspirate was white with calcified factor. After percutaneous coronary intervention, transthoracic echocardiography performed on day 25 revealed a hyperechoic mobile mass originating from the anterior mitral leaflet. As a mobile or rapidly increasing mass carries a high risk of embolism, we decided to perform surgical resection. Preoperative cerebral magnetic resonance imaging showed asymptomatic cerebral infarction, suggesting embolism by the cardiac mass. Resection of the cardiac mass was performed by cardiac surgeons. Microscopic pathology of cardiac mass revealed nodules of calcification and fibroblasts, leading to diagnosis of calcified amorphous tumor (CAT). Furthermore, the microscopic pathology of the coronary aspirate showed calcification, fibrin, and vascular endothelial cells. The pathological similarity of the cardiac mass and coronary aspirate indicated that the AMI has been caused by CAT. CAT causes systemic embolization; however, only 1 case of MI caused by CAT has been reported. We therefore experienced a rare case in which CAT caused AMI. .

[Open Surgery after Zone 0 Debranch Thoracic Endovascular Aortic Repair with Fenestrated Stent Graft:Report of a Case].

Thoracic endovascular aortic repair (TEVAR) has been widely used in recent years as a treatment for thoracic aortic aneurysm, but open surgery may be required for various complications that cannot be controlled by endovascular treatment alone. It is often a more challenging operation. A 78-year-old man underwent two debranch TEVAR (zone 1) for thoracic aortic aneurysm eight years before, and he received TEVAR (zone 0) again with the Najuta stent graft for re-expansion of aneurysm due to typeⅠa endoleak two years before. Since the aneurysm continued to expand and the aortic valve stenosis progressed after that, we performed total arch replacement (TAR) and aortic valve replacement (AVR). The Najuta stent graft could be removed manually. As the debranched graft had to be cut off at sternotomy, selective cerebral perfusion (SCP) was initiated at normal body temperature. It should be noted that SCP at normal body temperature may require more perfusion than hypothermic SCP. TAR was performed in combination with frozen elephant trunk, and postoperative computed tomography (CT) confirmed the disappearance of endoleak. One year has passed since the operation, but the aneurysm has not re-expanded.

Recurrent nonbacterial thrombotic endocarditis the day after mitral valve replacement.

Nonbacterial thrombotic endocarditis (NBTE) is relatively rare, with an identification rate of 1.6% at autopsy, and is associated with malignancy and systemic lupus erythematosus. Further, bioprosthetic valve NBTE is extremely rare, with only a few reports in the literature. To ensure appropriate treatment, it is essential to differentiate between NBTE from infective endocarditis (IE) as soon as possible, but this is difficult without information regarding underlying disease and sufficient time for careful investigation. Here, we report a case of recurrent NBTE of a bioprosthetic valve the day following surgery based on an initial diagnosis of IE. .

123I-BMIPP/201Tl dual myocardial SPECT proves the efficacy of surgical treatment for an adult with Bland-White-Garland syndrome.

Bland-White-Garland (BWG) syndrome is a rare congenital heart disease in which the left coronary artery originates from the pulmonary artery (PA). Surgical treatment to rebuild a dual coronary system is recommended at the time of the diagnosis. However, no effective operative procedure has been established for adult-type BWG patients because of the paucity of such cases. We herein report a case of adult-type BWG that was successfully treated by patch closure of the orifice of the left main tract from the main PA and coronary artery bypass grafting. 123I-15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP) and 201thallium (Tl) dual myocardial single-photon emission computed tomography (SPECT) were performed before surgery, early after surgery, and at three months after surgery. Before surgery, dual SPECT showed myocardial perfusion defects in the anterior and septal wall, which corresponded to the cardiovascular magnetic resonance imaging findings. Early after surgery, only 201Tl images demonstrated an improvement in the defect area. At three months after surgery, both the 201Tl and 123I-BMIPP imaging findings demonstrated an improvement in the defect area, which was correlated with the recovery of the left ventricular function. These results showed the effectiveness of this surgical approach for BWG syndrome. .

[Huge Left Thrombosis after Mitral Valvuloplasty and Maze Procedure;Report of a Case].

Generally, anticoagulation therapy is not essential for patients who maintain sinus rhythm after mitral valvuloplasty. A 66-year-old woman who had undergone mitral valvuloplasty and maze procedure for treatment of mitral valve regurgitation and atrial fibrillation 4 years ago was diagnosed as having left atrial thrombosis despite maintenance of sinus rhythm on electrocardiography. Echocardiography showed narrow mitral valvular area(1.5 cm2), loss of A wave and a huge left atrium. Repeat surgery was performed to replace the mitral valve and to remove the thrombus. The thrombus attached to the posterior wall of the left atrium with a wide basis, and was unrelated to the ablation line of maze procedure. Careful follow-up and anticoagulation therapy should be considered for patients who have a large left atrium and/or rheumatic mitral valve after valvuloplasty even though sinus rhythm is maintained.

Redefinition of tricuspid valve structures for successful ring annuloplasty.

BACKGROUND: Although numerous reports have described suturing techniques for tricuspid annuloplasty, most studies were not based on a detailed anatomy of the tricuspid annulus. Thus, the definition of the tricuspid commissures remains unclear. This study aimed to clearly define the commissures and leaflets of the tricuspid valve and subvalvular structures, and to define a standard method for tricuspid annuloplasty. METHODS: In 27 normal heart specimens without cardiac disease, the tricuspid commissure was defined using indentations of the leaflets as a point, not an area, and the length of each tricuspid annulus was measured. The relationships between the leaflets and the subvalvular structures were then examined. RESULTS: In most specimens, the posterior leaflet had 2 (62.9%) or 3 (29.6%) scallops, providing further evidence of posterior leaflet diversity. In addition, the posterior leaflet had 1 or 2 indentations, which can be mistaken for true commissures. The annulus of the posterior leaflet was significantly longer than the annuli of the other 2 leaflets (P < .00428). The annuli of the septal and the anterior leaflets were supported by the interventricular septum and the supraventricular crest, respectively, whereas the posterior leaflet annulus was distributed largely along the right ventricular free wall. CONCLUSIONS: There was a structural gap between the tricuspid leaflet indentations and the subvalvular structures. The relationships among the leaflets, commissures, and subvalvular structures differed in the septal, anterior, and posterior leaflets. This new definition of the commissural point may aid the development of a clear-cut methodology for prosthetic ring annuloplasty.

[Unplanned Ascending Aortic Graft Replacement at Valvuler Surgery in a Patient with Systemic Lupus Erythematosus;Report of a Case].

A 65-year-old woman with severe mitral stenosis was admitted to our hospital. She had been previously diagnosed with systemic lupus erythematosus (SLE) and had been taking prednisolone (5 mg/day) for 19 years. As SLE patients with prolonged steroid use are known to be at risk of an aortic dissection and aneurysm, femoral artery was chosen for arterial perfusion to reduce the risk of a dissection of the ascending aorta. However, hemostasis was difficult at the insertion point of the catheter to infuse the antegrade cardioplegic solution. An ascending aortic graft replacement was therefore performed. Histopathological examination of the aortic wall showed the presence of intimal hypertrophy and a decrease in elastic fiber content but without any evidence of vasculitis. Because prolonged steroids use is a risk factor of atherosclerotic change in the aortic wall, the aorta should be treated carefully during cardiovascular surgery in such patients.

Technique of managing periprosthetic leakage due to mitral prosthetic valve endocarditis: report of a case.

A patient with multiple leaks caused by active mitral prosthetic valve endocarditis with an annular abscess underwent repeat mitral valve replacement. To secure the new mitral prosthesis, sutures were placed through the healthy interatrial septal wall from right to left at the posteromedial region and then to the new prosthetic valve sewing cuff. In the anterolateral region, sutures were placed through the reconstructed annulus after debridement of the abscess and then reinforced with a pericardial xenograft patch. Postoperatively, the perivalvular leakage stopped and the patient recovered uneventfully.

[Octreotide acetate for persistent cylothorax after descending aorta replacement].

Cylothorax is one of a hazardous complication after thoracic aorta replacement. In this paper, we report effectiveness of octreotide acetate for postoperative persistent cylothorax. A 59-year-old female was referred to our hospital for chest pain. Previously she underwent arch reconstruction following aortic root replacement due to aortic dissection. Computed tomography (CT) revealed acute dissection on dissected descending aorta. Urgent descending aorta replacement was performed. After surgery, massive chylothoracic pleural fluid was drainaged. Although conventional medical treatment was not effective, drainage of chylothoracic pleural fluid significantly decreased after administration of octreotide acetate. Although mechanism has not been fully investigated, octreotide acetate was effective for persistent cylothorax after descending aorta replacement.

Reconsideration of patient-prosthesis mismatch definition from the valve indexed effective orifice area.

BACKGROUND: The objective of this study was to reassess the validity of defining patient-prosthesis mismatch (PPM) in the aortic position on the basis of an indexed effective orifice area (iEOA) less than 0.85 cm(2)/m(2). METHODS: From June 1996 to March 2008, 342 patients underwent aortic valve replacement with a Carpentier-Edwards Perimount valve. From the data collected, the transvalvular pressure gradient was determined by the modified Bernoulli equation, and EOA was calculated from the standard continuity equation. RESULTS: The actuarial survival rate at 10 years after surgery was 84.0% +/- 8.2%. The prevalence of PPM was 6.1% when a projected iEOA less than 0.85 cm(2)/m(2) was defined as indicating significant PPM. There was no difference between patients with moderate PPM (85.2% +/- 9.8%) and patients without PPM (81.0% +/- 8.7%; p = 0.44). The relation between mean transvalvular pressure gradient and iEOA demonstrated a gentler slope than that reported previously. Postoperative mean transvalvular pressure gradient was 17.4 +/- 5.6 mm Hg and 14.5 +/- 5.6 mm Hg in patients with an iEOA less than 0.85 and 0.85 or greater, respectively. Most patients had a postoperative mean transvalvular pressure gradient more than 10 mm Hg regardless of PPM. CONCLUSIONS: Our analysis suggested that an iEOA less than 2.0 cm(2)/m(2) might be the threshold for PPM, which should not be passed to achieve a low mean transvalvular pressure gradient (less than 10 mm Hg) with the Carpentier-Edwards Perimount valve. The implications of these findings include the necessity for reassessing the hemodynamic performance of each type of prosthesis when attempting to define PPM, to avoid residual significant transvalvular pressure gradient.

Active infective endocarditis: management and risk analysis of hospital death from 24 years' experience.

BACKGROUND: This study was performed to identify risk factors for hospital death in patients with acute and active infective endocarditis (AAIE) after surgical intervention. METHODS AND RESULTS: From 1980 to 2004, 94 patients underwent surgery for AAIE (age range, 3-77 years; 76% males). Congestive heart failure (CHF) was present in 44 patients, as well as vegetations in 64, septicemia in 16, abscesses in 17, and emboli in 22; 16 patients had prosthetic valve endocarditis. Streptococci were the most common bacteria (34 patients), followed by staphylococci (17 patients). Mechanical valves were selected for 73 patients and bioprosthetic valves for 16. Mitral valve plasty was performed in 4 patients. Aortic root or aorto-mitral discontinuity was repaired in 17 patients, including Manouguian's double valve replacement in 6 and aortic root replacement in 4. Overall hospital mortality was 15% (14 patients). Univariate analysis identified CHF (p=0.016), abscess (p=0.014), and prosthetic valve endocarditis (p=0.043) as risk factors. However, multivariate analysis only identified CHF (p=0.019) as an independent risk factor. CONCLUSION: In AAIE, early surgical intervention is advisable before the occurrence of complications such as root abscess and CHF, particularly before the onset of CHF.