Clinical Course of Residual Ventricular Septal Defects After Congenital Heart Disease Repair.

The clinical course of residual ventricular septal defects after congenital heart disease repair is not completely elucidated in the medical literature. This study assessed the incidence, size, and clinical course of residual defects.This single-center retrospective study included 132 patients who survived after ventricular septal defect patch closure (n = 107) and intracardiac repair of double-outlet right ventricle (n = 16) and tetralogy of Fallot (n = 9). Residual defect was evaluated on transthoracic echocardiogram upon hospital discharge and at outpatient clinic visits.The median age at surgery was 1.2 (0.3-13.9) years. In total, 45 (34.1%) patients presented with residual defects upon hospital discharge. The residual defects were within 2 mm (n = 27), 2-3 mm (n = 15), and > 3 mm (n = 3), and the median size was 1.5 (0.5-3.8) mm. There was no late mortality during a median follow-up of 5.4 years. Among 42 residual defects measuring < 3 mm upon hospital discharge, 37 (82.2%) spontaneously closed. Further, five defects decreased in size (1.8 ± 0.6 mm upon hospital discharge vs1.2 ± 0.8 mm at the latest visits, p = 0.15). However, the size of three residual defects measuring > 3 mm upon hospital discharge increased, and two patients required re-surgery for residual defect.Significant residual defect requiring reoperation was rare. In most cases, residual defects measuring < 3 mm upon hospital discharge spontaneously closed within 5 years, and the size of the other defects decreased.

Biventricular Repair Conversion After Temporary One and a Half Ventricular Repair for Hypoplastic Right Ventricle.

This case was an infant with critical pulmonary stenosis at birth. A temporary one and a half ventricular repair was performed to increase right ventricular end-diastolic volume and the size of the tricuspid valve annulus before biventricular repair conversion. The one and a half ventricular repair was performed using a unidirectional bicaval Glenn anastomosis. The right ventricular end-diastolic volume at 3 years was 73.2% of normal value but with a 64/36 right/left lung perfusion ratio. An anatomic biventricular correction included removal of the bicaval Glenn shunt and reconstruction of the continuity between the right and main pulmonary arteries. The one and a half ventricular repair made the reconstruction feasible.

A Successful Case of External Stenting for Bronchomalacia Lasting Over 20 Years.

We report on a patient with perimembranous ventricular septal defect and pulmonary hypertension. He underwent pulmonary artery banding followed by external stenting of the left bronchus because of secondary bronchomalacia. The external stent applied was a ringed expanded polytetrafluoroethylene graft, 10 mm in diameter and fixed at 8 points. Intracardiac repair was performed at the age of 2 years and the external stent was left in place. Since then, the patient has been healthy and computed tomography reveals that the external stent graft has retained function for over 20 years.

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.

[Warfarin effects diminishment by the Clostridium butyricum preparation after cardiac surgery; report of a case].

A 55-year-old gentleman diagnosed with severe aortic insufficiency and annuloaortic ectasia underwent modified Bentall procedure using mechanical valve. Anticoagulation therapy with warfarin was introduced after surgery, but sufficient anticoagulation effect was not achieved with a large amount of dosage. After discontinuing the use of the Clostridium butyricum preparation on postoperative day 29, sufficient anticoagulationt effect was obtained within several days. Clostridium butyricum might change the vitamin K production in the intestinal bacterial flora and attenuated the anticoagulation effect of warfarin.

Surgical results of reoperative tricuspid surgery: analysis from the Japan Cardiovascular Surgery Database†.

OBJECTIVES: Tricuspid valve insufficiency (TI) following cardiovascular surgery causes right-side heart failure and hepatic failure, which affect patient prognosis. Moreover, the benefits of reoperation for severe tricuspid insufficiency remain unclear. We investigated the surgical outcomes of reoperation in TI. METHODS: From the Japan Cardiovascular Surgery Database (JACVSD), we extracted cases who underwent surgery for TI following cardiac surgery between January 2006 and December 2011. We analysed the surgical outcomes, specifically comparing tricuspid valve replacement (TVR) and tricuspid valve plasty (TVP). RESULTS: Of the 167 722 surgical JACVSD registered cases, reoperative TI surgery occurred in 1771 cases, with 193 TVR cases and 1578 TVP cases. The age and sex distribution was 684 males and 1087 females, with an average age of 66.5 ± 10.8 years. The overall hospital mortality was 6.8% and was significantly higher in the TVR group than in the TVP group (14.5 vs 5.8%, respectively; P < 0.001). Incidences of dialysis, prolonged ventilation and heart block were also significantly higher in the TVR group than in the TVP group. Logistic regression analysis revealed that the risk factors of hospital mortality were older age, preoperative renal dysfunction, preoperative New York Heart Association Class 4, left ventricular dysfunction and TVR. CONCLUSIONS: Surgical outcomes following reoperative tricuspid surgery were unsatisfactory. Although TVR is a last resort for non-repairable tricuspid lesions, it carries a significant risk of surgical mortality. Improving the patient's preoperative status and opting for TVP over TVR is necessary to improve the results of reoperative tricuspid surgery.

Left ventricular aneurysm repair without ventriculotomy.

We describe a simple technique for left ventricular aneurysm without ventriculotomy. After confirming there is no thrombus in the left ventricular aneurysm, the aneurysm is pushed into the left ventricle and fixed with horizontal mattress sutures and running vertical sutures. This technique has quite low risk of bleeding.

Early outcome of folding mitral valve repair technique without resection for mitral valve prolapse in 60 patients.

OBJECTIVES: Leaflet resection represents the reference standard for mitral valve regurgitation. However, the resection technique is irreversible and requires leaflet cutting and reapproximation. Folding mitral valve repair is a nonresectional technique with inversion of the prolapsed segment into the left ventricle. The present study evaluated the effectiveness of this technique. METHODS: The prolapsed segment was inverted into the left ventricle vertically. A pilot suture was placed at the free edge of the leaflet. After confirming no mitral valve regurgitation with a pressure test, additional sutures were placed toward the annulus. If the test still showed mitral valve regurgitation, the suture was removed and repositioned. Ring annuloplasty was performed in all patients, except those with active infectious endocarditis. The repaired mitral valve was evaluated using echocardiography. RESULTS: A total of 60 patients (37 men; mean age, 62.4 years) underwent folding mitral valve repair from January 2007 to September 2011. Of these patients, 38 (63%) had moderate and 18 (30%) had severe mitral valve regurgitation preoperatively. Folding mitral valve repair was applied to the anterior leaflet and posterior leaflet. The mean cardiopulmonary bypass time and crossclamp time were 148 and 90 minutes, respectively. No patient had systolic anterior motion. Postoperative echocardiography revealed no mitral valve regurgitation to trivial mitral valve regurgitation in 48 and mild mitral valve regurgitation in 12 patients. No patient required reoperation for recurrent mitral valve regurgitation. CONCLUSIONS: Folding mitral valve repair is an easily fine-tuned technique with a pilot suture, which can be easily removed and repositioned, if unsatisfactory. This reversibility is a significant advantage of this technique. Long-term follow-up is necessary to assess the durability of this technique.

Rupture of thoracoabdominal aortic aneurysm associated with Behcet's disease.

Surgical treatment of arterial Behcet's disease (BD) has a higher incidence of graft-related complications such as anastomotic pseudoaneurysm or graft occlusion. A 64-year-old man presented with a rupture of the thoracoabdominal aortic aneurysms associated with BD. Evaluation shows a large hematoma in the retroperitoneum and multiple aneurysms of the thoracoabdominal aorta. Physical examination and past history fulfills the diagnostic criteria of BD. The abdominal aorta was replaced with an allograft and the major branches were reconstructed with its branches. The postoperative course was uneventful. A 10-month follow-up computed tomographic scan did not show any graft-related complications. This case suggests the usefulness of an allograft for arterial involvement of BD.

Aortic root replacements in reoperations.

We evaluated 4 patients who had undergone previous cardiac surgery underwent reoperation involving aortic root replacement. Subjects were a 55-year-old man who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 3.25 years earlier; a 51-year-old woman who had undergone separate valve graft replacement for a dissecting aneurysm (DeBakey type I) 6 years earlier; a 66-year-old woman who had undergone aortic valve replacement and single coronary artery bypass grafting for severe aortic regurgitation, angina pectoris, and aortitis syndrome 11 years earlier; a 47-year-old man who had undergone mitral valve replacement and 3-coronary artery bypass grafting for severe mitral regurgitation and angina pectoris 4 years earlier. Development of a surgical technique, coupled with myocardial protection, and pharmacological treatment at reoperation yielded excellent early surgical results. To reduce the incidence of reoperation and ensure satisfactory long-term results, we recommend radical management for the individual case be selected at initial operation and entire resections be conducted for aneurysmal degeneration or dissected segments.