[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.

[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.

Retrograde type A dissection after thoracic endovascular repair due to the barb.

We present a case of retrograde ascending aortic dissection in a 65-year-old man 8 months after emergency thoracic endovascular repair of an atherosclerotic aneurysm. Intraoperative findings identified a retrograde ascending aortic dissection due to the barb of the stent-graft. Retrograde type A dissection is a rare but fatal complication after thoracic endovascular aortic repair. There are some reports of retrograde ascending aortic dissection, but the etiology remains unclear. The subtle back-and-forth motion of the barb during the cardiac cycle may cause aortic injuries that result in retrograde ascending aortic dissection.

Surgical repair of isolated anterior mitral leaflet cleft via right minithoracotomy.

Isolated anterior mitral leaflet cleft (AMLC) is rare. Several surgical procedures have been described; however, there are few reports which described mitral repair using minimally invasive cardiac surgery for AMLC. We describe successful repair for isolated AMLC via right minithoracotomy. A 29-year-old woman with moderate mitral regurgitation (MR) diagnosed by echocardiogram several years previously presented with dyspnea on exertion. Transthoracic echocardiography revealed severe MR due to an AMLC in the central portion of A2. An autologous pericardial patch augmentation combined with artificial chorda reconstruction under right minithoracotomy approach was performed. It enabled to gain adequate leaflet coaptation area, and MR was effectively controlled by these procedures. .

Investigation of the surgical complications during thoracic endovascular aortic repair: experiences with 148 consecutive cases treated at a single institution in Japan.

PURPOSE: To investigate the risk factors associated with thoracic endovascular aortic repair at The Sakakibara Heart Institute of Okayama in Japan. METHODS: A total of 148 consecutive patients who underwent thoracic endovascular aortic repair between November 2009 and October 2012 were investigated. RESULTS: The patients' mean age at the time of the operation was 72.8 ± 11.7 years. The initial success rate of the procedure was 92.6 %. The 30-day mortality rate was 3.4 %, and the multivariable risk factors for mortality were urgent/emergency surgery and a sternotomy approach. The incidence of permanent stroke was 3.4 %. The multivariable risk factors for stroke included an age over 70 years and cases requiring the debranching procedure. The rate of paraplegia/paraparesis was 5.4 %. The mean follow-up was 14.8 ± 9.2 months, and the follow-up rate was 97.3 %. The overall mortality rate was 12.8 %. The survival rates after thoracic endovascular repair were 88.3 % in the first year, 87.0 % in the second year and 69.6 % in the third year. The freedom from aorta-related death rate was 97.1 % at 3 years. Primary technical success was a strong negative predictor of aorta-related death. CONCLUSIONS: The use of a debranching technique and sternotomy approach in patients with extensive atherosclerotic changes of the aortic arch were risk factors for major complications of TEVAR. Such patients may benefit from open surgery rather than TEVAR.

Hybrid treatment for type A acute aortic dissection with multiorgan malperfusion.

We present a hybrid surgical and endovascular repair for type A aortic dissection complicated with visceral ischemia. The patient had a history of coronary artery bypass grafting using the right gastroepiploic artery bypassed to the left anterior descending artery. Because of exacerbated metabolic acidosis and coronary ischemia caused by insufficient blood flow of the celiac artery and the superior mesenteric artery, the percutaneous transluminal angioplasty for both arteries was performed before surgical central repair. Hybrid operating room settings and equipment are considered to be a feasible option for treating patients with type A aortic dissection complicated with vital organ malperfusion.

Hybrid repair of right aortic arch aneurysm with a Kommerell's diverticulum.

We describe the case of a 74-year-old man who underwent a hybrid open and endovascular approach for repair of dissecting thoracic aortic aneurysm of a right aortic arch with aberrant left subclavian artery arising from a Kommerell's diverticulum. Total debranching using a tailored quadrifurcated graft and thoracic endovascular aneurysm repair for the transverse aortic lesion were performed. The procedures were successfully accomplished with complete exclusion of the aneurysm. This hybrid procedure for complex aortic arch disease may reduce perioperative complications compared to challenging conventional open approaches.

Preoperative Coil Embolization to Aortic Branched Vessels for Prevention of Aneurysmal Sac Enlargement Following EVAR: Early Clinical Result.

OBJECTIVE: Persistent Type 2 endoleaks (PT2) after endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) are associated with increased adverse outcomes, including aneurysmal sac enlargement and rupture. The aim of this study was to report early clinical outcomes of coil embolization (CE) to aortic branched vessels prior to EVAR and assess the effectiveness of this strategy in terms of prevention of sac growth due to PT2. MATERIALS AND METHODS: Between May 2007 and April 2012, EVAR was performed for 215 cases, divided into two groups (150 cases in Group A, before introduction of CE; 21 in Group B, receiving CE before EVAR). Early clinical outcomes were compared between groups. RESULTS: Fifty percent of cases in Group B had a marked reduction of aneurysmal sac diameter based on multi-detector row computed tomographic angiography (MDCTA) findings at the 6-month follow-up after EVAR, whereas, only 25% of cases in Group A had shrinkage of the aneurysmal sac during the same time period after EVAR. CONCLUSION: This strategy has the possibility of improving late outcomes of EVAR by reducing endoleak volumes beforehand.

Left ventricular thrombectomy using video-assisted thoracoscopy.

We report a case of a 40-year-old male who had a left ventricular thrombus with impaired cardiac function. The thrombus was completely removed using a video-assisted thoracoscopy via a right mini-thoracotomy. This approach is less invasive, avoiding sternotomy and ventriculotomy which can cause postoperative complications.

Branched graft inversion technique for distal anastomosis in total arch replacement.

Distal anastomosis during total arch replacement for thoracic aortic aneurysm is at times difficult, and bleeding from it is a serious problem because of its limited surgical exposure. We have modified a new procedure, the branched graft inversion (BGI) technique. We investigated the effectiveness of our technique by comparing it with the conventional stepwise technique. Between January 2008 and August 2011, 40 patients, divided into two groups of 20 each, underwent elective total arch replacement. One group underwent surgery using BGI; the stepwise technique was performed on the remaining 20 patients. Our modified BGI technique offers easy and secure distal anastomosis under good surgical procedure, resulting in shorter durations of operation, cardiopulmonary bypass, and circulatory arrest (455.1±101.3 min versus 354.7±49.3 min, p<0.001; 248.2±46.6 min versus 199.7±28.2 min, p<0.001; 76.6±27.7 min versus 61.6±10.4 min, p=0.029, respectively). As a result, this technique could be a useful in performing total arch replacement.

Port-access double valve replacement: first case report in Japan.

A 57-year-old man with mitral and aortic valve stenosis was admitted to our hospital. An electrocardiogram showed atrial fibrillation. After receiving informed consent, we performed a double valve replacement (DVR) with bioprostheses and maze procedure, utilizing a port-access technique. The operation and aortic cross-clamping times were 460 and 228 min, respectively. The patient's recovery was uneventful and he was discharged from our hospital with a consistent sinus rhythm 22 days after surgery. This is the first case report of port-access DVR in Japan.

[Effects of landiolol on hemodynamic improvement and prevention of atrial fibrillation in the perioperative period of off-pump coronary artery bypass grafting].

Recently, some clinical studies have suggested that beta-blockers may prevent atrial fibrillation after open heart surgery. In this study, we administered a low dose of landiolol (ultra short acting beta 1-blocker) by continuous infusion postoperatively to evaluate the effects on prevention of atrial fibrillation and hemodynamic stabilization in off-pump coronary artery bypass grafting (OPCAB). A total of 30 patients were given landiolol and studied as landiolol group (L group), and 50 patients who had undergone similar operations before were enrolled as control group (C group). Heart rate was significantly lower in L group without any deterioration of hemodynamics or myocardial disorder. Occurrence of atrial fibrillation within the 1st postoperative week in L group was statistically less than that in C group. Continuous infusion of landiolol in low dose has beneficial effects on hemodynamic stabilization, heart rate control, and prevention of atrial fibrillation in post-OPCAB.

[Surgical treatment of chronic constrictive pericarditis due to old tuberculosis; report of a case].

We experienced a case of pericardiectomy to treat constrictive pericarditis due to old tuberculosis. A 40-year-old woman was admitted to our hospital with dyspnea on exertion and edema of both legs. The chest computed tomography showed calcification of anterior ventricles. They were tightened up by calcified band. Subtotal pericardiectomy and removal of the calcification were performed without cardiopulmonary bypass. After the operation, symptoms were not disappeared in early phase. However, improvement for the patient was confirmed 3 months later.

[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.