Two-stage hybrid surgical repair for aortic arch pathology with a shaggy aorta: a case report.

BACKGROUND: The surgical treatment strategy for aortic arch pathology with a shaggy aorta must be determined on a case-by-case basis because of the risk of catastrophic complications, such as brain infarction and spinal cord injury. CASE PRESENTATION: This report describes the surgical case of two saccular aneurysms of the arch and abdominal aorta associated with a shaggy aorta in a 63-year-old man who underwent total arch replacement and secondary thoracic endovascular aortic repair. Considering the risk of embolization during endovascular therapy, graft replacement for the abdominal aortic aneurysm was initially performed. On postoperative day 28, total arch replacement with the conventional elephant trunk was performed using the functional brain isolation technique, which involves manipulating places far from the atherosclerotic burden, such as arterial inflow for cardiopulmonary bypass and unclamping of neck vessels. On postoperative day 7 after total arch replacement, thoracic endovascular aortic repair was performed across the conventional elephant trunk in the nondiseased descending aorta. No postoperative complications, such as cerebrovascular failure, paraplegia, or embolization to abdominal viscera or lower extremities, occurred. The patient remained asymptomatic. CONCLUSIONS: The present case suggests that total arch replacement with the conventional elephant trunk and secondary thoracic endovascular aortic repair may be an effective alternative for aortic arch pathology with a shaggy aorta. The strategy for surgical treatment in patients with aortic arch pathologies with a shaggy aorta must be judged on a case-by-case basis, considering patient characteristics, comorbidities, and preoperative evaluation using transesophageal echocardiography and computed tomography angiography, to eliminate potential determinants of intraoperative stroke.

Mitral valve replacement using a collar-reinforced mitral prosthesis for severe mitral annular calcification, which secures implantation in both the supra-annular and intra-atrial positions: a case report.

BACKGROUND: Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain. CASE PRESENTATION: This report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4-0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic. CONCLUSIONS: The present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.

Novel technique of repairing right partial anomalous pulmonary venous connection with intact atrial septum using in situ interatrial septum as a flap in a 68-year-old-woman: a case report.

BACKGROUND: Partial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown. CASE PRESENTATION: This study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic. CONCLUSIONS: The described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

Rapidly vanishing left atrial dissection following mitral valve replacement: a case report.

BACKGROUND: Left atrial dissection is an extremely rare complication of mitral valve replacement. Because of its severity, its prompt diagnosis and treatment is mandatory. The most effective treatment (i.e. surgical vs. non-surgical) for left atrial dissection has not been fully established yet. CASE PRESENTATION: Herein, we have reported left atrial dissection after mitral valve replacement in a 68-year-old obese woman. After closing the thorax, transesophageal echocardiography (TEE) revealed an atrial mass of 3 cm × 2 cm, visualized as an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Because hemodynamic conditions were stable, surgery was ruled out and conservative treatment with close observation was selected. On postoperative day 2, TEE revealed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium was normalized completely, leaving no traces of left atrial dissection. The patient recovered uneventfully. Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection. CONCLUSIONS: It is crucial to accurately define diagnosis and optimally consider therapeutic strategies for left atrial dissection based on the hemodynamic conditions of the patient and serial TEE follow-up examinations. In our case study, left atrial dissection was successfully treated with conservative treatment; therefore, we believe that TEE could be a feasible modality for the early diagnosis of this condition.

Surgical Treatment for Kommerell's Diverticulum Associated with a Right-Sided Aortic Arch and an Aberrant Left Subclavian Artery: Endovascular or Hybrid.

A right-sided aortic arch, associated with an aberrant left subclavian artery and a Kommerell's diverticulum, is a rare congenital anomaly. Case 1: A 53-year-old man, complaining of dysphasia, underwent a two-stage hybrid operation. Total arch replacement with the reconstruction of supra-aortic vessels was performed via a median sternotomy. Thoracic endovascular aortic repair was subsequently completed with the femoral approach. Case 2: A 81-year-old man, complaining of syncope and dizziness, underwent thoracic endovascular aortic repair after endovascular aneurysm repair for a common iliac artery aneurysm. Treatment strategies for Kommerell's diverticulum should be individually determined depending on the clinical situation and anatomical features.

[Aortitis Syndrome Requiring Redo Bentall Procedure with Coronary Artery Bypass Grafting due to Graft Detachment;Report of a Case].

A 53-year-old woman was referred to us for reoperation of aortic root. Twenty-three years ago, she was diagnosed with aortitis and suffered from annuloaortic ectasia, aortic regurgitation, severe stenosis of left carotid and subclavian arteries and occulusion of the main trunk of left coronary artery. The left coronary system was perfused by collateral arteries from right coronary artery. She had undergone original Bentall procedure( Cooley graft 26 mm+SJM valve 25 mm) with coronary artery bypass grafting (CABG)[saphenous vein graft (SVG)-left anterior descending artery (LAD)]. When she was 52 years old, she suffered from angina on efforts. Computed tomography and catheter angiocardiogram revealed pseudoaneurysm formation due to detachment of right coronary artery button and occulusion of SVG. We underwent redo aortic root replacement (Hemashield graft 26 mm+On-X valve 23 mm) with redo CABG (SVG-LAD). Eight mm graft was interposed between composite valve graft and right coronary button. Postoperative course was uneventful. She was discharged from the hospital on the 17th day, and is now doing well without any symptoms.

Root aneurysm following aortic valve replacement 20 years after an arterial switch operation.

Late development of annuloaortic ectasia (AAE) and progression of aortic regurgitation (AR) are widely recognized outcomes following an arterial switch operation (ASO). We treated a 29-year-old male with AAE and rapid aortic root expansion, who underwent ASO as a neonate and aortic valve replacement (AVR) as an adult. He was diagnosed as having dextro-(D-loop) transposition of the great arteries after birth and underwent ASO at the age of 13 months. At the age of 19 years, AVR was performed for progressive AR. AAE developed after AVR. In patients who have undergone neonatal ASO, AAE may occur following AVR decades later.

Antegrade thoracic endovascular aortic repair using an ascending aortofemoral through-and-through wire technique for a severely tortuous aorta associated with rickets.

BACKGROUND: Severe aortic tortuosity of the access route often prevents successful complete exclusion of an aneurysm in thoracic endovascular aortic repair (TEVAR). CASE PRESENTATION: We performed antegrade TEVAR on a 79-year-old man with right hemiparesis. We deployed the stent graft from the ascending aorta with a tube graft conduit to treat a descending thoracic aortic aneurysm associated with rickets and multiple comorbidities. Although the application of a ministernotomy diminished the potential advantages of endovascular treatment in view of less invasive surgery, antegrade TEVAR using an ascending aortofemoral through-and-through wire technique was a good option in this patient because a conventional retrograde approach was not feasible due to his severely tortuous aorta. CONCLUSIONS: To avoid device-related complications, it is crucial to make a prudent preoperative decision on a patient-by-patient basis, taking into account the appropriate access site, adjuvant guidewire technique, and adjunctive surgical interventions.

[Migration of a Temporary Epicardial Pacing Lead into the Vascular Graft].

A 48-year-old man was refered to our hospital for the treatment of bicusp aortic valve and severe aortic regurgitation. He underwent Bentall procedure (SJM 25mm+HemashieldØ 28 mm composite graft). Temporary epicardial pacing lead( TPL) was placed on the right ventricle at the opetation, and was cut on his skin surface prior to discharge because of difficulty in traction removal. After 15 years from operation, follow up computered tomography and echocardiography showed migration of 2 retaining TPLs extending from vascular graft of ascending aorta to the right innominate artery. We performed Redo-median sternotomy and removed the TPLs. This is the 1st reported case of a migrated temporary pacing lead into the vascular graft of ascending aorta under noninfectious conditions.

Open-heart surgery using a centrifugal pump: a case of hereditary spherocytosis.

BACKGROUND: Hereditary spherocytosis is a genetic, frequently familial hemolytic blood disease characterized by varying degrees of hemolytic anemia, splenomegaly, and jaundice. There are few reports on adult open-heart surgery for patients with hereditary spherocytosis. CASE PRESENTATION: We report a rare case of an adult open-heart surgery associated with hereditary spherocytosis. A 63-year-old man was admitted for congestive heart failure due to bicuspid aortic valve, aortic valve regurgitation, and sinus of subaortic aneurysm. The family history, the microscopic findings of the blood smear, and the characteristic osmotic fragility confirmed the diagnosis of hereditary spherocytosis. Furthermore, splenectomy had not been undertaken preoperatively. The patient underwent a successful operation by means of a centrifugal pump. Haptoglobin was used during the cardiopulmonary bypass, and a biological valve was selected to prevent hemolysis. No significant hemolysis occurred intraoperatively or postoperatively. CONCLUSION: There are no previous reports of patients with hereditary spherocytosis, and bicuspid aortic valve. We have successfully performed an adult open-heart surgery using a centrifugal pump in an adult patient suffering from hereditary spherocytosis and bicuspid aortic valve.

Bileaflet mechanical valve replacement: an assessment of outcomes with 30 years of follow-up.

OBJECTIVES: Heart valve replacement with a bileaflet mechanical valve is a well-established procedure. However, the long-term results of valve replacement using the bileaflet mechanical valve remain unclear, especially for follow-up periods over 30 years. Additionally, it is important to identify predictors of long-term mortality and valve-related events. METHODS: We performed a retrospective cohort analysis of 2727 patients (mean ± standard deviation age, 52.8 ± 1.6 years) who underwent valve replacement with a St. Jude Medical valve at our institute from 1978 to 2012. Data were collected using a questionnaire and chart review or physician contact. The cohort included 950 aortic valve replacements (AVRs), 1255 mitral valve replacements (MVRs) and 522 double valve replacements (DVRs). Follow-up was 91% complete, and the analysis included a total of 39 187 patient-years. RESULTS: Operative mortality rates were 2.3% for AVR, 2.2% for MVR and 3.6% for DVR. The 30-year survival rate (actuarial method) was 38.0% (AVR, 44.5%; MVR, 34.9%; and DVR, 37.5%). The 30-year rates of freedom from valve-related mortality, thromboembolic events and bleeding events were 86.3% (AVR, 88.6%; MVR, 85.4%; and DVR, 84.3%), 83.5% (AVR, 89.8%; MVR, 80.0%; and DVR, 81.4%) and 91.5% (AVR, 94.4%; MVR, 90.1%; and DVR, 90.2%), respectively. The incidence rates of valve-related morbidity, thromboembolic events and bleeding events were significantly higher among patients with MVR and DVR than among those with AVR. Significant risk factors for late death and other late events included male sex, age >65 years and atrial fibrillation. CONCLUSIONS: Low late mortality and a low incidence of valve-related events can be achieved for at least 30 years using mechanical bileaflet valve replacement. Persistent atrial fibrillation is a significant risk factor for morbidity and mortality.

Open Surgery for Giant Bilateral Internal Iliac Artery Aneurysms with Compression of Neighboring Abdominal Structures: A Case Report.

We describe a patient with successfully treated giant bilateral internal iliac artery aneurysms that were associated with acute renal failure secondary to bilateral hydronephrosis, lumbosacral plexopathy, and ileus. After hemodialysis for 1 month, the patient underwent graft replacement of the abdominal aorta and iliac arteries, including complete obliteration of the internal iliac artery branches, reconstruction of the inferior mesenteric artery, and ureterolysis. Weaning from hemodialysis was achieved and postoperative renal function improved. Although the patient had serious preoperative co-morbidities, emergency traditional open surgery should be the gold standard for securely releasing compression of the neighboring organs instead of endovascular treatment.

[Off-pump Coronary Artery Bypass Surgery Following Aortic Root Replacement for Acute Type A Dissection ; Report of a Case].

A 45-year-old male presented to our hospital with worsening heart failure. Computed tomography coronary angiography revealed total occulusion of the proximal left anterior descending artery (LAD). The patient had a history of acute type A dissection,and had undergone aortic root replacement. Avoiding prosthetic graft injury and bleeding,coronary revasculizaion was accomplished by left anterior thoracotomy using the left internal thoracic artery without cardiopulmonary bypass. The postoperative course was uneventful.

Surgery for aortic regurgitation and aortic root dilatation in Takayasu arteritis.

BACKGROUND: Special consideration may be required for surgical treatment in Takayasu arteritis because inflammation may cause serious complications such as valve detachment or dilatation of the residual aorta. We evaluated our surgical outcome of treatment for aortic regurgitation and aortic root dilatation in Takayasu arteritis. METHODS: Between December 1983 and January 2013, 22 cardiac operations were performed in 20 patients with aortic regurgitation due to Takayasu arteritis. Aortic valve replacement was carried out in 6 patients, and aortic root replacement in 16. Of these 16 patients, composite graft replacement was undertaken in 6, composite graft replacement plus coronary artery bypass grafting in 2, composite graft replacement plus total or partial arch replacement in 7, and valve-sparing aortic root replacement with hemiarch replacement in one. RESULTS: The operative mortality (within 30 days) was 4.5% and the 5-year survival rate was 90.9%. Early surgical reintervention was not required in any patient. Neither valve detachment nor composite graft detachment was noted. Two patients required redo aortic root replacement due to pseudoaneurysm formation and severe aortic regurgitation during follow-up. Late dilatation of the residual thoracoabdominal or abdominal aorta was observed in 2 patients, and both were treated surgically. CONCLUSIONS: The early surgical outcome was acceptable but surgical reintervention was required because of late dilatation of the residual aorta or recurrent aortic regurgitation due to annular dilatation, and longstanding careful follow-up will be needed.

Large mitral valve aneurysm with infective endocarditis.

A 63-year-old man with infective endocarditis (IE) was admitted to our hospital after experiencing acute heart failure. A two-dimensional transthoracic and transesophageal echocardiography revealed vegetation attached to both aortic and mitral valves, a very large mitral valve aneurysm, a severe mitral regurgitation jet issuing from a mitral valve perforation and severe aortic regurgitation. Three days after admission, both the aortic and mitral valves were replaced. The patient received antibiotic therapy for 6 weeks postoperatively and recovered with no neurological complications. Although the patient was discharged without recurrence of IE, his transthoracic and transesophageal echocardiography showed periprosthetic mitral regurgitation, requiring him to receive close follow-up monitoring. This case report exemplifies the rather unusual, but important, complications of aortic valve IE, and suggests some suitable forms of intervention.

Delayed visceral and spinal cord malperfusion after axillo-bifemoral bypass for complicated acute type B aortic dissection.

We describe a successfully treated case of acute type B aortic dissection complicated with lower extremity, visceral, and spinal cord malperfusion. To restore perfusion to both lower extremities, we performed an emergency right axillo-bifemoral bypass. Furthermore, we performed total arch replacement, including primary entry closure, because of delayed visceral organ ischemia. Unexpectedly, delayed paraplegia occurred after hospital discharge; however, the patient recovered without any neurologic sequelae after early introduction of hyperbaric oxygen therapy. Because another episode of organ malperfusion in the long term cannot be anticipated, and even though the previous organ malperfusion episode was treated successfully, close observation is mandatory for detecting clinical manifestations in combination with the availability of imaging modalities.

Simultaneous surgery for patent ductus arteriosus associated with papillary fibroelastoma.

We describe a case of patent ductus arteriosus (PDA) in a 76-year-old woman with a history of stroke, atrial fibrillation, and chronic obstructive pulmonary disease. Cranial diffusion-weighted imaging (DWI) performed for preoperative assessment showed a hyperintense lesion in the left cerebellum. Preoperative transesophageal echocardiography (TEE) demonstrated two highly mobile masses approximately 5 mm in diameter adherent to the left and non-coronary cusps of the aortic valve. We performed transpulmonary patch closure of PDA under hypothermic circulatory arrest. Subsequently, two frond-like masses were completely shaved off the cusps, preserving the native aortic leaflets. Pathological examination confirmed the diagnosis of papillary fibroelastoma (PFE). To our knowledge, this is the first report of PDA associated with PFE. Perioperative use of TEE is an effective tool for management of cardiovascular patients with suspected cardiogenic embolism.

The effect of ventricular sequential contraction on helical heart during pacing: high septal pacing versus biventricular pacing.

OBJECTIVE: To investigate the effect of biventricular and high septal pacing on the normal contraction sequence of the helical ventricular myocardial band, and its impact on left ventricular function. METHODS: Ten pigs (25-68 kg) underwent analysis of percent segmental shortening (SS%) by sonomicrometry, with crystals placed along the fiber orientation of the ascending, descending segments, and posterior LV wall within the spatial geometry of the helical heart. Unipolar pacing electrodes stimulated the right atrium (RA) and either the right ventricular apex and left ventricular posterior wall (atrio-biventricular), or the proximal high septum (atrio-high septal). Systemic hemodynamics, QRS-interval, cardiac index (CI), systolic and diastolic LV functions and pressure-dimension loops (P-D) were analyzed and cardiac motion was monitored by video analysis. RESULTS: Pacing increased normal sinus heart rate (NSR) from 77+/-9 beats/min to 98+/-5 beats/min. Atrial pacing did not change the NSR hemodynamic variables. Conversely, atrio-biventricular pacing prolonged the QRS-interval (91+/-14 ms vs 56+/-11 ms at baseline, p<0.05) and decreased mean arterial pressure (50+/-4 mmHg vs 58+/-12 mmHg), CI (3.4+/-0.3 L/(min m2) vs 4.0+/-0.8 L/(min m2)) and PRSW (71+/-25%) compared to NSR (p<0.05). Furthermore, atrio-biventricular pacing decreased SS% in all segments, especially at the LV posterior wall (71% of baseline, p<0.05), and disrupted the NSR shortening sequence (progression from descending to posterior to ascending regions). Changes were characterized by premature stimulation of the posterior wall segment adjacent to the pacer stimulus, with associated (1) decrease of pressure-dimension loop area, (2) desynchronization of P-D loops and (3) consistent loss of the twisting pattern of visible cardiac motion. In contrast, atrio-high septal pacing restored systemic hemodynamics, LV systolic and diastolic functions to baseline values and preserved the normal sequence of shortening of the ventricular myocardial band. CONCLUSIONS: (1) Biventricular pacing disrupts of the natural sequence of shortening of the myocardial band and results in impaired LV function. (2) High septal pacing preserves the sequential shortening pattern of the myocardial band and LV function.