Aortic valve replacement in a patient with left ventricular noncompaction.

Left ventricular noncompaction is a rare cardiac pathology that results from an arrest in endomyocardial development in early embryogenesis. With great advances in imaging modalities, this pathological entity has been noted not only in the pediatric population but also in adults. Herein we report the case of a 62-year-old woman who successfully underwent aortic valve replacement for aortic regurgitation complicated by left ventricular noncompaction.

[Aortic root replacement with a freestyle stentless valve for prosthetic valve detachment caused by aortitis syndrome; report of a case].

A surgical case of a 65-year-old man with aortitis syndrome is presented. The patient had undergone aortic valve replacement for aortic valve regurgitation with a mechanical prosthesis, followed by a re-do operation (valve fixation) for prosthetic valve detachment 6 months after the 1st operation. Three months after the 2nd operation, perivalvular leakage due to valve detachment was detected again. Aorticroot replacement with a Freestyle stentless valve( full root technique) was performed. Prednisolone was given postoperatively, and no valve detachment nor pseudoaneurysm formation has been noted for 8 years.

[Stepwise technique of the proximal anastomosis with the new proximal anastomotic system for the prevention of kinking of the graft].

In using the proximal anastomotic system, the anastomotic site should be carefully selected to prevent the kinking of the graft, because the angle of the graft and the aortic wall is perpendicular. There recommended anastomotic sites are the left lateral aortic wall adjacent to the pulmonary artery for the left coronary system grafting and the lower aortic wall adjacent to the right atrium for the right coronary system grafting respectively. When the selection of these sites are difficult because of the atherosclerotic lesion of the aorta, the short vein graft (2-3 cm) was first anastomosed with PAS-Port device to the site free from atherosclerosis. Then, the long vein graft was anastomosed to the short graft with monofilament suture under end-to-side fashion. The angle of the anastomosis was decided according to the relationship of the aorta and the target coronary artery to establish a smooth graft line. By this stepwise technique, the optimal graft design could be obtained without a risk of the kinking of the graft.

Re-do mitral valve replacement using the valve-on-valve technique: a case report.

We report a repeated mitral valve replacement (re-do MVR) using the valve-on-valve technique for a degenerated bioprosthesis. A 49-year-old female, who had had a 29 mm Carpentier-Edwards mitral bioprosthesis for mitral regurgitation 20 years previously, was referred to our institution for dyspnea. She presented with pulmonary edema secondary to severe mitral bioprosthetic valve regurgitation. We replaced the degenerated mitral bioprosthesis with a 25 mm mechanical prosthesis using the valve-on-valve technique, as the struts of the bioprosthesis were embedded in the left ventricular myocardium. Removal of the bioprosthesis may be not only time-consuming but also complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall. The valve-on-valve technique is a simplified procedure that can avoid the potential complications of complete excision of the bioprosthesis. We believe this technique can be a useful strategy for patients with a degenerated mitral bioprosthesis.

A technique of snaring method for fitting a prosthetic valve into the annulus.

BACKGROUND: Tourniquetting technique to fit a prosthetic valve (PV) into the annulus in valve replacement surgery has been previously reported. We modified the previously reported method and designed a simpler tying technique. PATIENTS: We performed 11 aortic (AVR: including four cases for calcified aortic stenosis (AS) with a small annulus and one cases for infective endocarditis with intramuscular abscess cavity), eight mitral valve replacements (MVR), and one tricuspid valve replacement (TVR: for corrected transposition of the great arteries). TECHNIQUES AND RESULTS: A PV was implanted using 2-0 polyester mattress sutures with a pledget. Each of the two tourniquets held a suture at the bottom of the annulus and at the opposite position to fit a PV. The sutures between each snare were tied down from the bottom to the top. In MVR, after seating of a PV with two tourniquets, we could make sure that no native tissue of any preserved mitral apparatus disturbed PV leaflet motion. In calcific AS, a PV had a good fitting into the annulus because of tourniquets applied to unseated part during tying sutures. In AVR for infective endocarditis, mattress sutures supported by a Teflon pledget were placed to close the abscess cavity. After snaring on one of these sutures, we tied down the sutures, ensuring that they did not cut through the friable tissues. In TVR, we found that native leaflets interfered with PV motion after seating down the prosthesis and those leaflets were resected before tying down the sutures. Postoperative transesophageal echocardiography showed no paravalvular leakage in any patients and excellent PV functions.

Off-pump quintuple coronary artery bypass grafting for situs inversus totalis.

Dextrocardia associated with situs inversus totalis is a rare condition. A 49-year-old man with dextrocardia and situs inversus totalis underwent off-pump quintuple coronary artery bypass grafting using bilateral internal thoracic arteries and bilateral radial arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. His postoperative recovery was uneventful.

Concomitant mitral valve repair and left ventricular reconstruction in a patient with chronic ischemic mitral regurgitation and inferior left ventricular aneurysm.

The surgical approach to ischemic mitral regurgitation with concomitant inferior left ventricular aneurysm remains uncertain in terms of the indication for operation and the short- and long-term outcomes. We performed concomitant mitral valve repair, left ventricular reconstruction, and aortic valve replacement on a 71-year-old male with severe ischemic mitral regurgitation, inferior left ventricular aneurysm, and degenerative aortic regurgitation. Postoperative status was in New York Heart Association functional class I without mitral regurgitation 8 months after operation. We discuss, and review the procedures reported in the literature.

Aortic valve replacement in a patient with a patent internal thoracic artery graft.

Myocardial protection in patients requiring a second open-heart surgical procedure after coronary artery bypass grafting, especially when there is a patent left internal thoracic artery graft to the left anterior descending coronary artery, remains controversial. We present the case of a patient in whom aortic valve replacement was undertaken 18 months after coronary artery revascularization. Unusual features included beating-heart aortic valve replacement with continuous retrograde coronary sinus perfusion and avoidance of dissection of the patent grafts, including the left internal thoracic artery and a saphenous vein graft.

Feasible pericardiotomy for off-pump coronary artery bypass.

Pericardiotomy is the first essential step for the exposure of the coronary artery in off-pump coronary artery bypass (OPCAB) via a median sternotomy. After the dissection of the pericardium from the pleura, a longitudinal pericardiotomy from the apex to the aortic reflection was employed. The pericardiotomy was extended transversely to make a trapezoidal flap. By the traction of the left pericardium, anterior vessels were well exposed. For the closure, a trapezoidal pericardial flap was useful.

Concomitant transabdominal MIDCAB and abdominal aortic aneurysm repair.

We present 2 patients who underwent transabdominal minimally invasive direct coronary artery bypass with the right gastroepiploic artery combined with abdominal aortic aneurysm repair. The surgical procedures, both performed through a median laparotomy, proved safe and of limited invasiveness. The one-stage surgical intervention prevented catastrophic complications, such as acute myocardial infarction or rupture of abdominal aortic aneurysm. We believe that concomitant transabdominal minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair should be considered as a single combined surgical strategy in selected patients.

Does skeletonization compromise the integrity of internal thoracic artery grafts?

BACKGROUND: There are few reports that demonstrate the chronologic changes in the functional integrity of the internal thoracic artery (ITA) wall after skeletonization. We investigated the impact of skeletonization on ITA wall integrity by immunohistochemical analyses in acute and chronic phases. METHODS: Nine mongrel dogs underwent bilateral ITA dissection with one skeletonized vessel and the other pedicled. The following studies were performed 1 week (acute phase, n = 3) and 12 weeks (chronic phase, n = 6) after ITA harvesting. All specimens of the ITAs were stained by antibodies against von Willebrand Factor (VWF), endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), and proliferating cell nuclear antigen (PCNA). After observation with confocal laser scanning microscopy, quantitative analyses of the staining signal for VWF and eNOS expressed on endothelial cells were performed. RESULTS: There were significantly more microvessels positive for VWF in the adventitia of skeletonized ITAs than in the adventitia of pedicled ITAs but the expression of PCNA in both groups was minimal, as in normal vessels. iNOS was not detected in any specimen. The intensity of VWF and eNOS expressed by endothelial cells had no significant differences between groups at either phase. CONCLUSIONS: The functional integrity of skeletonized ITA was similar to that of pedicled ITA in both acute and chronic phases. Although skeletonization induced neovascularization in the adventitia it did not induce proliferation of smooth muscle cells in the media, which is supposed to be a feature of vascular remodeling.

Surgery for cardiomyopathy with mitral regurgitation and dyssynchrony.

We present a case of dilated cardiomyopathy with medically intractable congestive heart failure, which was improved by surgical intervention including mitral valve repair and biventricular pacing. This strategy is effective against dilated cardiomyopathy with interventricular dyssynchrony and mitral regurgitation.