Mitral Valve Regurgitation in Klippel-Feil Syndrome With Related Thoracic Deformity.

Klippel-Feil syndrome, characterized by congenital fusion of any 2 or more cervical vertebrae, is a rare disorder in which skeletal and other organ system-related abnormalities have been reported. This article reports a case of mitral valve regurgitation in a patient with Klippel-Feil syndrome and related thoracic deformity who underwent mitral valvuloplasty. Postoperatively, the mitral valve regurgitation disappeared, and there has been no recurrence for 3 years. This case highlights mitral valvuloplasty via median sternotomy as an excellent treatment for mitral valve regurgitation in a patient with thoracic deformity related to Klippel-Feil syndrome.

[Modified Warden Procedure for Correction of Partial Anomalous Pulmonary Venous Connection and Sinus Venosus Atrial Septal Defect in an Adult].

A 32-year-old woman was referred to our hospital for the surgical indication of sinus venosus-type atrial septal defect. Preoperative computed tomography scan revealed that the right upper pulmonary vein returned to the high superior vena cava. We performed a modified Warden procedure using a pedicle flap of the right atrial appendage along with a fresh autologous pericardium. Her postoperative course was uneventful with no venous obstruction or sinus node dysfunction. This technique is a useful surgical option for a partial anomalous pulmonary venous connection especially in adults.

[Postinfarction Ventricular Septal Perforation Treated with the Sandwich Method Using a Right Ventricular Approach;Report of a Case].

The patient was a 75-year-old man who presented to our hospital with complaints of palpitation and a cold sensation. Echocardiography revealed ventricular septal perforation(VSP) at the base of the posterior septum. As his hemodynamic condition was stable, patch closure of the VSP was performed on the 50th hospital day after fibrosis at the infarction site developed. Under cardiac arrest, an incision directed toward the cardiac apex was made at the base of the right ventricular inferior wall. Closure of the VSP was performed using double-patch sandwich technique:a bovine pericardial patch on the left, and a Dacron patch on the right ventricular side. The postoperative course was uneventful.

[A Single-knot Lock Procedure for Adjustment of Artificial Chordae in Mitral Valve Repair].

We describe a simple and reproducible technique for adjustment of neochordal length in mitral valve repair with a single-knot lock procedure. A small loop with polytetra fluoroethylene(CV-4)is secured on the papillary muscle as an anchor for the neochordae. A needle with CV-5 suture is passed through the anchor loop, and both ends of the suture are passed through the free edge of the prolapsed mitral leaflet. A single knot is made on the leaflet with the 2 ends of each suture thread, and the ends of each pair of suture threads are secured with small hemostatic clamps. The hemostatic clamps are suspended over the edge of the wound to apply traction to the single knot. The knot is locked with this tension and the friction between the threads. The saline injection test is applied, and the height of the artificial chordae is adjusted by sliding the knot to the appropriate position. After valve competency is obtained, the knot is held by curved hemostatic forceps, and the threads of the suture are tied on the leaflet. This technique for adjustment of neochordal length is quick, reliable, reproducible, and increases the technical possibilities for mitral valve repair.

[Technique to Reinforce Double-barreled Distal Aortic Anastomosis in the Repair of Aortic Dissection].

We describe a technique to reinforce a double-barreled aortic anastomosis in the repair of chronic aortic dissection. After distal aortic resection was carried out, an intimal flap was incised lineally 1 cm in width along with its margin. This intimal band was reapproximated to the adventitia which supported the false lumen. The wedge-shaped excision was made on the residual intimal flap to maintain blood flow to both the true and false lumens. Two felt strips were circumferentially placed inside and outside of the aortic edge, and the layers were sandwiched together with monofilament sutures. Finally, the prosthetic graft was anastomosed to the reinforced aortic stump with continuous suture. If the length of the intimal edge was shorter than that of the dissected adventitia, the intima was incised in a long, triangular shape from its base to form 2 ligulate flaps. The flaps were then slid together and attached to the corresponding adventitia, and the aortic stump was reinforced using the sandwich technique. This technique may be an effective and safe method for reinforcement of a double-barreled aortic anastomosis in the repair of chronic aortic dissection.

[Novel Device for Creating Multiple Artificial Chordae Loops in Mitral Valve Repair].

A novel device to create multiple artificial chordae loops for mitral repair is developed. The device consists of a circular metal base with a removable central rod on one end, which can easily be attached or removed by screwing into a hole located on the base, and 51 fixed rods placed radially around the central rod at distances of 10~60 mm from the central rod. A needle with CV-4 e-polytetrafluoroethylene suture is passed through a pledget, and the suture is looped from the central rod around the fixed rod located at the desired loop length. The needle is then passed back through the pledget. The suture is tied over the pledget, bringing it in contact with the central rod. When multiple loops of various lengths are required, different fixed rods located at distances corresponding to the required loop lengths are used. Following creation of the necessary loops, the central rod is unscrewed, and the loops are released from the device. Construction of artificial chordae with this device is quick, reliable, reproducible, and increases the technical possibilities for mitral valve repair.

Acute aortic regurgitation due to aortic dissection confined to the sinus of Valsalva.

A 34-year-old man with severe heart failure was diagnosed with acute aortic regurgitation (AR) by transthoracic echocardiography (TTE). However, this differential diagnosis was incomplete. Only transesophageal echocardiography (TEE) revealed an intimal flap, leading to a diagnosis of Stanford type A aortic dissection. No abnormal findings were observed in the ascending aorta by contrast-enhanced computed tomography (CT). Aortic dissection confined to the sinus of Valsalva has rarely been reported; however, TEE should still be considered for the differential diagnosis of acute AR, even if there is no evidence of dissection by TTE or contrast-enhanced CT.

Effect of landiolol hydrochloride after off-pump coronary artery bypass.

OBJECTIVES: many studies have shown that oral beta blockers reduce the incidence of atrial fibrillation after coronary artery bypass. The goal of this study was to determine whether landiolol, an intravenous beta blocker, reduces the incidence of atrial fibrillation after off-pump coronary artery bypass. METHODS: 39 consecutive patients were given landiolol after coronary artery bypass, and 20 who were not given landiolol served as a control group. Landiolol was intravenously administered at 1 µg.kg(-1).min(-1) in the intensive care unit. RESULTS: the mean dose of landiolol was 2.3 ± 1.2 1 µg.kg(-1).min(-1). The incidence of atrial fibrillation during intensive care unit stay was significantly lower in the landiolol group compared to the control group: 2.6% (1/39) vs. 20% (4/20). Heart rate after landiolol administration was significantly lower than that before administration, whereas landiolol had no effect on blood pressure. C-reactive protein and creatine kinase levels 7 days after surgery were significantly lower in the landiolol group. CONCLUSION: continuous administration of landiolol at a low dose after off-pump coronary artery bypass reduced the incidence of atrial fibrillation.

Diaphragmatic hernia following coronary artery bypass surgery with the right gastroepiploic artery: case report and literature review.

We report an unusual case of intrapericardial diaphragmatic hernia 2 years after coronary artery bypass surgery with the right gastroepiploic artery. Herniation through the orifice created for the right gastroepiploic artery caused small bowel strangulation and secondary volvulus requiring extensive small bowel resection due to acute mesenteric ischemia. This case highlights the importance of careful operative management of coronary artery bypass surgery with the right gastroepiploic artery and increases awareness of this rare but potentially fatal complication.

Paraplegia due to spinal epidural hematoma after mitral valve surgery: report of a case.

Spinal epidural hematomas are rare entities that can be associated with spinal traumatic injuries and vascular lesions or that can spontaneously arise. Several reports have linked these hematomas to heart valve surgery. We herein describe a 71-year-old female patient who developed postoperative paraplegia immediately after mitral valve repair. Magnetic resonance imaging revealed an epidural hematoma of the spinal cord from C7 to Th4. A laminectomy was not performed because the patient's paraplegia gradually improved. After continuous rehabilitation, the patient regained sufficient muscle strength to perform standing exercises. She is presently capable of routine activities at home and is undergoing bethanechol chloride treatment for a neurogenic urinary bladder. Motor and sensory deficits of both lower limbs in a patient that arise immediately after heart surgery must be examined by early imaging to rule out space-occupying pathologies such as spinal epidural hematomas.

Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery.

The purpose of this study was to assess the feasibility and effectiveness of graft fixation with a novel side graft holder for sequential or composite graft anastomosis in coronary artery bypass grafting (CABG). Records of 34 patients who underwent CABG using sequential or composite graft anastomosis technique were reviewed. The device was used on 47 anastomoses (sequential=43; composite graft=4). Excellent fixation and visualization of the graft was obtained in all patients without graft injury. Postoperative angiographic patency rate of distal anastomoses was 95.2% (arterial, 91.2%; venous, 96.7%). All sequential and composite graft anastomoses were patent and without stenosis. One operative death occurred due to low cardiac output after emergent CABG for acute myocardial infarction. No elective patient died during hospitalization. Postoperative complications occurred in two patients (ventricular fibrillation, 1; postoperative catheter intervention, 1). No perioperative myocardial infarctions or re-operations occurred. Our clinical experience shows that graft fixation with the device is safe, reliable, and effective for sequential and composite graft anastomosis during CABG.

A simple and safe technique for positioning a bipolar radio-frequency device for pulmonary vein isolation.

We describe a simple and safe technique to position a bipolar radio-frequency ablation device around the pulmonary veins when performing pulmonary vein isolation. The technique consists of insertion of a rubber catheter with stylet, originally an introducer from a left vent catheter, behind the pulmonary veins, and subsequent placement of the lower jaw of the ablation clamp using a rubber catheter to guide the device into position. This novel method avoids excessive compression or displacement of the heart and enables easy and safe positioning of the ablation device around the pulmonary veins.

A novel side graft holder for coronary artery bypass grafting.

We describe the construction and use of a novel side graft holder for coronary artery bypass grafting. The device is a hammer head-shaped clip used to hold the graft side securely but atraumatically during sequential or composite graft anastomosis. The side graft holder provides gentle stabilization and excellent visualization of the side of the graft without causing graft injury.

Prosthetic mitral valve leaflets jammed by a balloon catheter.

We encountered a case in which prosthetic mitral valve leaflets were jammed by a transmitral balloon catheter during mechanical mitral valve replacement. The catheter, which was inserted in the left ventricle to render the leaflets incompetent during de-airing, forced the leaflets into the closed position. The leaflet edges pinched the catheter lumen and obstructed balloon deflation. Excessive inflation of the balloon and extraction of the catheter before complete deflation of the balloon should be avoided to prevent a potentially serious complication.

Initial clinical experience with a new end graft holder for anastomosis in coronary surgery.

OBJECTIVE: We assessed the feasibility and effectiveness of a novel end graft holder for coronary artery bypass grafting (CABG) and evaluated anastomotic patency and early clinical results. METHODS: The end graft holder was applied to 45 consecutive patients. Operative characteristics were off-pump CABG in 22.2%, emergency in 28.9%, and concomitant cardiac surgery in 13.3%. RESULTS: The device was used safely without graft injury or inadequate gripping on grafts. Postoperative angiography showed that the patency rate of distal anastomosis was 96.7% (arterial, 100%; venous, 94%). All proximal aortic and composite graft anastomoses were patent without stenosis. The rate of 30-day major adverse cardiac and cerebrovascular events was 13.3% (operative deaths, 3; repeated CABG, 1; percutaneous coronary arterial intervention, 1; and cerebral infarction, 1). None of the elective patients died during hospitalization. CONCLUSION: Our initial clinical experience demonstrated that the new end graft holder was safe, reliable, and effective during CABG. The excellent fixation and visualization of the graft with the device might be particularly beneficial for off-pump CABG or for teaching trainees.

[Surgical technique of displacement and retraction of the heart with a pigtail shaped hook and Tentacles Heart Positioner].

We describe a novel heart retracting system with Tentacles Heart Positioner (Sumitomo Bakelite, Tokyo) during off-pump coronary artery bypass grafting (OPCAB). The heart retracting system is composed of a pigtail shaped hook attached to a flexible Universal Stabilizer Arm (Estech, Minneapolis). After Tentacles suction device is applied on the surface of the heart, the retracting system is fixed on the sternal retracter so that the hook can hang and support the retracting tubes of the sucker. By regulating the shape of the Universal Stabilizer Arm and the position of the hook, the retracting system can lift the heart sufficiently and maintain the optimal position of the heart during OPCAB procedure. Together with Tentacles Heart Positioner, the heart retracting system provides excellent exposure of target coronary arteries with minimal effect on hemodynamics.

New anastomosis assist devices for coronary artery bypass grafting.

Two new graft holders and an anastomosis assist mirror, designed for coronary artery bypass grafting, are described. The graft holders are pinching devices with sponges inside to prevent graft injury. The anastomosis assist mirror is a small circular mirror designed to show a reflective view of the lateral or posterior wall of the heart. Together they can provide secure stabilization of the graft and an excellent view of the anastomotic site.

A new end graft holder for coronary artery bypass grafting.

This article describes the construction and use of a new end graft holder during coronary artery bypass grafting (CABG). The instrument consists of a pinching device attached to a flexible arm and a fixation clamp. This device provides secure stabilization and enables excellent positioning of the graft without producing graft injury.

[An anastomosis assist mirror; a new device for off-pump coronary artery bypass].

An anastomosis assist mirror for off-pump coronary artery bypass (OPCAB) is described. This new device is designed to make a view of the circumflex coronary artery which is often troublesome to access during OPCAB. It is composed of 3 parts: a small circular mirror, a paper clip and a flexible arm between the mirror and the clip. The paper clip is situated at an edge of a sternal retractor. The mirror is positioned beside the sheer surface of the lateral wall of the heart by regulating the flexible arm. It shows a flat, reflective view of the anastomotic site and makes an anastomosis easy. The device enables us to avoid excessive manipulation on the heart and hemodynamic instability, thereby reducing unnecessary volume overload, inotropic drugs or mechanical cardiac assistance.