[Debranching Endovascular Repair for Impending Rupture of Aortic Arch Aneurysm in an Eldery Patient;Report of a Case].

Recently, thoracic endovascular aortic repair( TEVAR) has emerged as an alternative to open repair. We reported a case of a 92-year-old woman who underwent successful TEVAR for impending rupture of aortic arch aneurysm. The patient presented with back pain. Computed tomography revealed an impending rupture site at the aortic arch and left hemothorax. First, an axilo-axilo-carotid artery bypass was performed, and then 2 thoracic stent grafts were deployed successfully. Her postoperative course was uneventful, and at day 20, she was discharged. Debranching TEVAR is an effective procedure for aortic arch aneurysms in elderly patients.

Successful bicuspid aortic valve repair using external aortic annuloplasty.

A 33-year-old man presented with severe aortic insufficiency due to a prolapsed bicuspid aortic valve. The ventriculoaortic junction was dilated to 29 mm without root dilatation, and external ring annuloplasty was performed using a Gelweave (Terumo, Tokyo, Japan) graft to reduce the size to 22 mm. The leaflets were repaired by dividing and suturing a raphe between the right and left cusps. This combination provided adequate coaptation depth (8 mm) and showed excellent results, with trivial aortic insufficiency. This approach is suitable for repair of a bicuspid aortic valve with a dilated ventriculoaortic junction without root dilatation.

Mid-term results of tricuspid annuloplasty using the MC3 ring for secondary tricuspid valve regurgitation.

We investigated mid-term outcomes after ring annuloplasty with the MC3 ring and aimed to identify factors associated with recurrent tricuspid regurgitation (TR). From October 2006 to October 2010, 136 patients (male:female 80:56, with a mean age 64.7±11.8 years) underwent tricuspid valve (TV) annuloplasty for functional TR. The indications for TV annuloplasty were (1) severe TR, or (2) mild or moderate TR with pulmonary hypertension (systolic pulmonary artery pressure >50 mmHg) or tricuspid annular (TA) dilatation, in patients undergoing mitral valve (MV) surgery. The average follow-up period was 1.5±0.8 years. The overall survival rates were 97.1±0.15%, 93.4 ± 0.02% and 90.7 ± 0.28% at three months, one year and four years, respectively. Freedom from recurrent moderate TR was 98.5±0.01, 95.6 ± 0.17% and 90.6 ± 0.03% at three months, one year and four years, respectively. Multivariate analysis revealed that residual TR was significantly associated with preoperative severe TR, left ventricular end-diastolic dimension >70 mm, right ventricular dimension >40 mm, dilated cardiomyopathy (DCM) and left ventriculoplasty. This MC3 ring corrects TR effectively, and provided good results. We must point out, however, that additional or alternative surgical options should still be considered for high-risk of repair failure, such as those with DCM or high pulmonary hypertension.

Left ventriculoplasty for dilated cardiomyopathy in Fukuyama-type muscular dystrophy.

A 29-year-old man was hospitalized because of heart failure causing dilated cardiomyopathy (DCM). On admission, he had elevated creatinine kinase levels (hyper CKemia) (4283IUl⁻) and false enlargement of bilateral calves. By a muscular biopsy, he was diagnosed as Fukuyama-type muscular dystrophy. Although neuromuscular diseases are often related to cardiomyopathy, reports showing a relation between cardiomyopathy and Fukuyama-type muscular dystrophy have been rare. Our group performed the partial left venticulectomy of the posterior wall and approximation of the papillary muscle, mitral valve annuloplasty, and tricuspid valve annuloplasty for DCM in the patient with Fukuyama-type muscular dystrophy, after obtaining informed consent from the patient and his family. At the 1-year follow-up examination, the neuromuscular symptoms had not progressed, and the left ventricular function was improved (left ventricular end-diastolic dimension (LVDd) 77-66 mm, left ventricular end-systolic dimension (LVDs) 73-59 mm, and ejection fraction (EF) 26-30%). This is the first case report of a left ventriculoplasty in a patient with Fukuyama-type muscular dystrophy.

Alternative technique for implanting an epicardial cardioverter defibrillation patch during a tricuspid valve replacement for arrhythmogenic right ventricular cardiomyopathy.

Transvenous endocardial cardioverter defibrillator lead implantation is contraindicated in patients with prosthetic tricuspid valves (TVs). A 61-year-old male was hospitalized due to right heart failure, severe TV regurgitation, and non-sustained ventricular tachycardia (VT), which required Sotalol. The patient received an implantable cardioverter defibrillator (ICD) using an epicardial cardioverter defibrillation patch during a TV replacement (TVR) for VT and severe TV regurgitation because of arrhythmogenic right ventricular cardiomyopathy. There were no complications and the stimulation thresholds were stable. ICD implantation with the use of an epicardial cardioverter defibrillation patch serves as a safe, easy and effective therapy for patients undergoing TVR complicated with ventricular arrhythmia.

Surgical outcome of simultaneous carotid and cardiac surgery.

PURPOSE: The surgical outcome of a simultaneous carotid endarterectomy and cardiac surgery has not been clarified. This study retrospectively reviewed short- and mid-term outcomes after a carotid endarterectomy combined with valvular surgery or coronary artery bypass grafting (CABG). METHODS: Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range 59-86 years) underwent a carotid endarterectomy combined with cardiac surgery. The main indication for carotid endarterectomy was more than 75% carotid stenosis with or without cerebral ischemic symptom. Eight patients had a history of stroke or transient ischemic attack. Endarterectomy was performed under mild hypothermia and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass in all cases. Concomitant cardiac procedures were aortic valve replacement in 1 patient and CABG in 14 patients. RESULTS: There was no early death. Early neurological complications occurred in only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein increased significantly in those that suffered postoperative neurological complications. One patient died 6 months after the operation due to pneumonia. There was no myocardial infarction, and no events were observed in the late postoperative periods. CONCLUSIONS: Carotid endarterectomy can be safely performed in combination with cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels might be useful for predicting early neurological complications.

First clinical application of the DuraHeart centrifugal ventricular assist device for a Japanese patient.

The DuraHeart ventricular assist device (VAD) is a third-generation implantable centrifugal pump with a magnetically levitated impeller. Since February 2007, the device has been clinically applied with excellent results as a bridge to heart transplantation in Europe. As of this writing, however, the device has yet to be approved by the Ministry of Health, Labour and Welfare for clinical use in Japan. We herein report the first clinical application of this device for a Japanese patient. A 31-year-old man with dilated cardiomyopathy was transferred to the Heart and Diabetes Center NRW (HDZ-NRW) in Bad Oeynhausen, Germany, where he was to await heart transplantation. The transfer was safely completed under management with low-dose dopamine. His condition gradually deteriorated at HDZ-NRW, and the DuraHeart left ventricular assist device was implanted for the left ventricle at 7 weeks after admission. Shortly thereafter, however, on POD 7, a Thoratec VAD had to be inserted on the right side due to refractory right heart failure. The right ventricular assist device could be explanted after a 3-month assist, and the patient is now waiting for heart transplantation at home in Germany.

Reconstructive surgery for an akinetic anterior ventricular wall in ischemic cardiomyopathy.

BACKGROUND: The purpose of this prospective study is to analyze the postoperative outcome after only left ventricular reconstruction (LVR) versus LVR combined with coronary artery bypass grafting (CABG) and/or mitral valve (MV) procedure in ischemic cardiomyopathy (ICM) as a result of an akinetic anterior ventricular wall. METHODS AND RESULTS: Nineteen patients underwent only LVR, and 37 underwent a concomitant LVR procedure. In both groups, New York Heart Association (NYHA) classification improved significantly from 3.5 +/- 0.6 to 2.2 +/- 0.5 (LVR group) and 3.4 +/- 0.7 to 2.5 +/- 0.5 (combined LVR group). Ejection fraction improved significantly from 25.1 +/- 3.2 to 35.3 +/- 4.5% in the LVR group and 28.1 +/- 2.2 to 37.6 +/- 5.5% in the combined LVR group. Cardiac index improved significantly from 1.8 +/- 0.6 to 2.3 +/- 0.5 l/min/m2 in the LVR group and 1.6 +/- 0.4 to 2.2 +/- 0.6 l/min/m2 in the combined LVR group. An additional concomitant procedure increased the mortality rate only slightly. The overall 1- and 5-year actuarial survival rates were 90% and 75% in the LVR group and 80% and 70% in the combined LVR group. CONCLUSIONS: The LVR for akinetic ventricular wall shows very satisfactory early and long-term results. The LVR, with or without concomitant procedures, has considerable benefits for operative therapy.

Multiple papillary fibroelastomas in rare locations of aortic valve and left ventricular outflow tract: a case report.

Papillary fibroelastoma (PFE) is the third most common primary neoplasm of the heart. The lesions generally appear singly, but multiple PFEs may rarely occur. The case is reported of multiple PFEs in a woman initially admitted for acute cerebral infarction. Echocardiography revealed four masses, one located on each cusp of the aortic valve and one on the left ventricular outflow tract. All four lesions were successfully removed surgically. An histopathologic examination revealed PFEs arising from the ventricular and valvular endocardium.

A case report of central extracorporeal membrane oxygenation after implantation of a left ventricular assist system: femoral vein and left atrium cannulation for ECMO.

PURPOSE: The left ventricular assist system (LVAS) is often used for end-stage heart failure. However, in severe lung disorder, the patient needs extracorporeal membrane oxygenation (ECMO) because oxygenation using only a ventricular assist system (VAS) is insufficient. We report a successful case of combining the use of LVAS and right VAS (RVAS) with ECMO. METHOD: A 40-year-old female developed cardiogenic shock secondary to end-stage dilated cardiomyopathy, and percutaneous cardiopulmonary support (PCPS) was initiated. An echocardiogram showed a low ejection fraction (11%), and she underwent implantation of an LVAS (Toyobo Ventricular Assist System). She also required a RVAS with ECMO shunting between the right and left atrium because there was insufficient oxygenation resulting from pulmonary dysfunction followed by severe lung edema. RESULT: Pulmonary function recovered successfully, and the RVAS-ECMO was removed after 7 days of support. There were no complications after operation, such as infection, bleeding, or systemic embolization. CONCLUSION: LVAS combined with RVAS-ECMO in right and left atrial cannulation is a useful option for patients with severe pulmonary damage.

The CardioWest total artificial heart for chronic heart transplant rejection.

Mechanical circulatory support has been used to treat graft failure after heart transplantation, but in patients who needed mechanical circulatory support because of chronic rejection, we have suffered from the treatment because its outcome was catastrophic. Multiple organ failure was often caused by the addition of or increase in immunosuppressive medications, and it is known as a cause of the poor outcomes. The CardioWest total artificial heart was implanted for a case of chronic heart transplant rejection to enable complete withdrawal of immunosuppressive medication. The patient underwent re-heart transplantation, with a good result. This is a new therapeutic technique for chronic graft rejection.

Reoperation for aortic valve stenosis due to severe calcification of the bioprosthetic valve after modified Bentall operation in Takayasu arteritis.

Takayasu arteritis is an inflammatory disease that affects the aorta and its main branches. The dilation of the aortic root would cause aortic regurgitation (AR). We would demonstrate the dramatic change of the bioprosthesis implanted in the young woman with Takayasu arteritis, which has not been reported previously, and we believe that bioprosthesis should not be implanted easily in Takayasu arteritis.

Mechanical circulatory support for fulminant myocarditis.

PURPOSE: Fulminant myocarditis is potentially fatal because it progresses rapidly into cardiogenic shock; thus, immediate and appropriate treatment is essential. Mechanical circulatory support (MCS) is an important part of treatment for fulminant myocarditis. We review our experience of treating fulminant myocarditis with MCS. METHODS: We used MCS with veno-arterial bypass (VAB) to treat seven patients with fulminant myocarditis. Five of these patients were younger than 18 years old. The mean time from arriving at our institution to the initiation of MCS was 15.9 +/- 22.6 h. MCS was initiated within 18 h in six patients. RESULTS: The mean assist time of MCS was 70.9 +/- 35.0 h and six patients were weaned successfully (weaning rate: 85.7%). The remaining patient required support with VAB for 132 h, and a left ventricular assist device was applied. All seven patients were weaned off MCS and discharged. CONCLUSIONS: Since severe and rapid hemodynamic compromise is typical of fulminant myocarditis, an immediate decision must be made about whether to initiate MCS. We attribute the excellent results and favorable long-term prognosis of our patients to the early initiation of MCS.

Should emergency surgical intervention be performed for an octogenarian with type A acute aortic dissection?

OBJECTIVE: The number of octogenarians undergoing emergency surgery is increasing and may negate the impact of the beneficial advances. The aim of this study was to review octogenarians with type A acute aortic dissection and assess the prognosis. METHODS: Fifty-eight patients with acute aortic dissection, whose average age was 83.2 years, were divided into 2 groups: Group I comprised 30 patients who underwent emergency surgery, and group II comprised 28 patients who were treated conservatively. We compared the 2 groups in terms of mortality and morbidity. RESULTS: In group I, postoperative hospital mortality was 13.3% (4 patients). In group II, 17 patients (60.7%) died in the hospital. In group I, although emergency aortic replacement was successfully completed, 5 patients became bedridden after surgery and 2 patients died of pneumonia or stroke in the early stages of institutional care. Thirteen patients in group I died of malignancies, abdominal aortic rupture, traffic accident, heart failure, or late-stage senility in later phase. There was no difference in actuarial survivals at 5 years, which were 48.5% in group I and 35.4% in group II. CONCLUSION: Emergency surgery for octogenarians with acute aortic dissection showed acceptable mortality. However, families had to take responsibility for patients who experienced unconsciousness, had dementia, or became bedridden. It is important to have consensus between the family and surgeons about emergency surgical treatment for octogenarians.

First report of Bartonella quintana endocarditis in Japan.

Bartonella (Rochalimaea) species are increasingly recognized as a cause of endocarditis, but the total number of cases remains low. Especially, Bartonella quintana endocarditis is very rare and there have been no reports in Japan. A 66-year-old man was hospitalized because of dyspnea and fever. An echocardiogram showed severe mitral valve regurgitation, mild aortic valve regurgitation, and echogenic masses on the mitral and aortic valve. Six sets of blood cultures were negative. Replacement of the mitral- and aortic-valve with a mechanical valve was performed. However, due to symptomatic para-valvular leakage a re-mitral valve replacement was later performed. Unfortunately, the patient died 1 month after the operation owing to multiple organ failure. Four weeks after the second operation, blood culture yielded a Gram-negative bacillus. DNA was extracted from the colony and subjected to polymerase chain reaction amplification. Nucleotide sequence analysis (1,500 nucleotide positions) and a BLAST search of the EMBL/GENBANK database revealed 99.9% homology with the Bartonella quintana 16S rRNA gene. This is the first report of Bartonella quintana endocarditis in Japan, and should be considered with the view of culture negative endocarditis.

Long-term survival after cardiac retransplantation: a single-center experience.

Cardiac retransplantation is controversial therapy because of a chronic shortage of donor hearts. We retrospectively reviewed short- and long-term outcomes after cardiac retransplantation. Between February 1989 and December 2004, 28 cases of cardiac retransplantation were performed. Indications for retransplantation were primary graft failure (PGF) in 11 patients (39.3%), intractable acute cardiac rejection (IACR) in 4 (14.3%), and coronary allograft vasculopathy (CAV) in 13 (46.4%). The patients had been supported with prolonged cardiopulmonary bypass (CPB) (n = 3), IABP (n = 1), intravenous inotropic support (n = 7), ECMO (n = 3), and VAD (n = 4). Ten patients had no inotropic support. Eight patients died within 30 days postoperatively. The causes of early death were acute rejection (n = 3 ; 37%), MOF (n = 3 ; 37%), PGF (n = 1 ; 13%), and right ventricular failure (n = 1 ; 13%). The causes of late death in 8 other patients were acute rejection (n = 4 ; 50%), CAV (n = 2 ; 25%), MOF (n = 1 ; 13%), and infection (n = 1 ; 13%). The 1-, 5-, 10-, and 15-year survivals were 78.5, 68.4, 54.5, and 38.3%, respectively, for primary cardiac transplantation, and 46.4, 40.6, 32.5, and 32.5% for cardiac retransplantation (P = 0.003). Acute cardiac rejection was the most common cause of death (43.8%). Thirty-day and 1-year survivals of IACR, PGF, and CAV were 50.0/0, 63.6/45.5, and 84.6/68.4%, respectively. Long-term survival after retransplantation was acceptable for patients with CAV and PGF, however, we should select patients carefully if the indication for retransplantation is IACR because of the poor outcome.

A simple and safe operation method for brachiocephalic artery aneurysms.

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.

Successful treatment of fulminant myocarditis with mechanical circulatory support.

A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.

Vascular protecting effect of angiotensin receptor blocker (ARB) on the radial artery graft.

PURPOSE: We hypothesized that the vascular protecting effect of an angiotensin receptor blocker (ARB) reduced endothelial damage of the radial artery (RA) after coronary bypass and conducted a comparative study. PATIENTS AND METHODS: One hundred and sixty four patients were divided into the following two groups, Group C: 92 subjects who were orally administered Candesartan 8 mg/day, Group I: 72 subjects who were administered Imidapril at 5 mg/day. Graft angiography was performed one year after surgery and the RA intima was evaluated using an angioscope. RESULTS: Total cholesterol of Group C was 151.4+/-66.9 mg/dL, which was significantly lower than in Group I (182.2+/-27.8 mg/dL), and LDL cholesterol of the ARB-treated group, i.e., Group C was 96.1+/-32.5 mg/dL and significantly lower than in Group I (139.1+/-48.7 mg/dL). In angioscopy, yellow plaque was detected in the proximal RA in 7 (8.0%) and 8 (11.6%) patients of the Groups C and I, respectively, showing a lower tendency in the ARB-treated group. CONCLUSIONS: The results of evaluation one year after surgery revealed no significant difference in effects on the RA endothelium between ARB and ACE inhibitor. ARB reduced cholesterol and its effect was confirmed with blood examination data and endoscopic findings.

First case report in Japan of left ventricular pacing via a coronary vein in a patient with a mechanical tricuspid valve.

Transvenous endocardial pacemaker implantation is contraindicated in patients after prosthetic tricuspid valve replacement. A 65-year-old woman underwent both replacement of the mitral and tricuspid valves and pacemaker implantation with epicardial lead for bradycardia with chronic atrial fibrillation. At 2 years after this operation, the pacemaker's battery became low, and she was admitted for a battery exchange. To avoid frequent battery exchanges because of high stimulation thresholds, a left ventricular pacing lead was implanted via a coronary vein. There were no complications and the stimulation thresholds were stable. Coronary vein leads enable a minimally invasive approach, improve safety, and give effective stimulation for patients with a prosthetic tricuspid valve. This is the first case report in Japan of left ventricular pacing in such a patient.