Left ventricular outflow tract obstruction caused by massive mitral annular calcification in a patient with hypertensive heart disease.

Mitral annular calcification (MAC) is frequently observed, but it rarely causes left ventricular outflow tract (LVOT) obstruction (LVOTO). An 83-year-old woman with hypertension, diabetes, and dyslipidemia was admitted to our hospital because of exertional dyspnea. She was diagnosed with hypertensive heart disease. Her symptoms were exacerbated by exertion, and she had no symptoms at rest. Transthoracic echocardiography showed massive posterior MAC, a sigmoid septum, and LVOTO, with a peak gradient of 15.4 mmHg at rest. Systolic anterior motion of the anterior mitral leaflet was not found. Moreover, the LVOT gradient in the stress condition was evaluated, and an increased LVOT gradient (47.3 mmHg) and chest discomfort was noted after 20 µg/kg/min of dobutamine was administered and the Valsalva maneuver was used. Hence, the patient was diagnosed with latent LVOTO. Interestingly, the distance between the septal wall, which was protruding into the left ventricular cavity, and the mitral valve coaptation, which was pushed up by the posterior MAC, had become closer, causing dynamic LVOTO. Since it is difficult to treat LVOTO with medication, ultimately, septal myectomy and mitral valve replacement were performed, which improved her symptoms. Evaluating the LVOT pressure gradient in stress condition is important in patients with MAC. .

Left ventricular restoration for cardiac sarcoidosis: report of two cases.

Although sarcoidosis may involve the myocardium, there is little available information on its treatment, especially in cases requiring surgery, such as left ventricular restoration or mitral valve repair. This report presents two surgical cases with cardiac sarcoidosis treated by left ventricular restoration and mitral valve repair for a ventricular aneurysm and dilated cardiomyopathy with mitral regurgitation.

False aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case.

A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu's arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438-445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.

Double-patch repair by a bilateral ventriculotomy for postinfarction ventricular septal defect.

OBJECTIVES: Repair of a postinfarction ventricular septal defect (VSD) is a challenging procedure with a high risk of postoperative residual shunt and subsequent mortality. This retrospective study aimed to assess a modified infarct exclusion technique with a biventricular approach. METHODS: Nineteen consecutive patients who underwent the infarct exclusion procedure for VSD between 2002 and 2011 were reviewed. A biventricular approach (B group: 6 patients) and a left ventricular approach (L group: 13 patients) were studied by univariate analysis. RESULTS: The overall 30-day mortality was 15.8%, and was not different between the two groups (p=0.94). Postoperative residual shunt was not observed in the B group (p=0.21). The overall five-year survival rate was 79%, and there were no late deaths in the B group (p=0.14). CONCLUSION: The repair of postinfarction VSD can be safely performed by the infarct exclusion technique with a biventricular approach. This technique seems to reduce surgical mortality and prevents recurrence of the VSD.

Mid-term echocardiographic comparison of chordal preservation method of mitral valve replacement in patients with mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: The efficacy of chordal-preserved mitral valve replacement (MVR) on left ventricular function was investigated in patients with mitral stenosis. METHODS: Eighty patients (25 males, 55 females; mean age 64.5 +/- 8.7 years) with pure mitral stenosis who underwent MVR between January 1999 and May 2008 were studied retrospectively. Of these patients, 20 had total chordal-preserved MVR (group I), 36 had posterior leaflet-preserved MVR (group II), and 24 had MVR without chordal preservation (group III). Echocardiographic assessments were performed preoperatively and at four years postoperatively. RESULTS: Both, preoperatively and intraoperatively, there were no significant differences between the three groups. Mid-term echocardiography showed significant improvements in the left ventricular ejection fraction (LVEF) of the chordal preservation groups (group I, 55 +/- 12% to 60 +/- 7%, p = 0.017; group II, 56 +/-10% to 61 +/- 8%, p = 0.025), whereas the LVEF was significantly decreased after non-chordal-preserved MVR (group III, 56 +/- 7% to 49 +/- 11%, p = 0.036). Furthermore, the non-chordal preservation group demonstrated a significant increase in left ventricular volumes (end-diastolic volume, from 92 +/- 15 ml/m2 to 107 +/- 23 ml/m2, p = 0.005, end-systolic volume, from 43 +/- 7 ml/m2 to 58 +/- 20 ml/m2, p < 0.001) and a spherical change in left ventricular geometry (sphericity index, from 1.6 +/- 0.2 to 1.3 +/- 0.2, p < 0.001). CONCLUSION: Chordal preservation during MVR resulted in an improved ejection performance and the maintenance of left ventricular volume in mitral stenosis. However, these hemodynamic advantages were similar after total chordal preservation and posterior leaflet preservation.

Long-term results of bioprosthetic tricuspid valve replacement: an analysis of 25 years of experience.

BACKGROUND: Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series. METHODS: We retrospectively studied the early and late results of 32 consecutive patients (7 male and 25 female; mean age 60.2 ± 18.1 years) undergoing bioprosthetic tricuspid valve replacement between 1985 and 2010. The etiology is rheumatic in 38 %, congenital in 3 %, endocarditis in 9 %, and functional in 50 %. Patients underwent isolated valve replacement. The remaining underwent combined aortic and tricuspid (n = 5, 16 %), mitral tricuspid (n = 15, 47 %), and aortic, mitral, and tricuspid (n = 1, 3 %) valve replacement. Preoperative liver dysfunction was evaluated using Model for End-stage Liver Disease (MELD) score. Mean follow-up was 5.6 ± 6.8 years (ranging from 0 to 25.0 years). RESULTS: Hospital mortality was 19 %. On univariate logistic regression analysis, NYHA class IV (p = 0.039, odds ratio 11.3, 95 % confidence interval 1.2-112.5), MELD score (>10) (p = 0.011, odds ratio 21.0, 95 % confidence interval 12.0-222.0) and congestive liver (p = 0.05, odds ratio 9.4, 95 % confidence interval 1.0-93.5) were incremental risk factors for hospital death. The 15- and 25-year actuarial survival were 56.5 ± 10.3 % and 45 ± 13.0 %, respectively. Multivariate analysis using Cox proportional hazard model showed MELD score (p = 0.024, hazard ratio 7.0, 95 % confidence interval 2.1-23.9) and postoperative pulmonary hypertension (p = 0.012, hazard ratio 4.4, 95 % confidence interval 1.4-14.1) were significantly associated with decreased survival. At 15 years, freedom rates from tricuspid valve reoperation, anticoagulation-related bleeding, and valve related events were 85.7 ± 13.2 %,95.7 ± 4.3 % and 81.8 ± 13.2 %, respectively. The linearized incidence of structural valve deterioration was 0.50 %/patient-year, anticoagulation-related bleeding was 0.94 %/patient-year, and valve-related events were 1.52 %/patient-year. CONCLUSION: Preoperative hepatic congestion and liver dysfunction which were indicated by the MELD score >10 were associated with poor outcome for patients undergoing tricuspid valve replacement. The MELD score is useful to predict the morality among these patients.

Aortic root reimplantation for isolated sinus of valsalva aneurysm in the patient with Marfan's syndrome.

We describe an isolated extracardiac unruptured acquired aneurysm in the right coronary sinus of Valsalva, which was seen in a 55-year-old woman with Marfan's syndrome. The patient underwent aortic root replacement using a reimplantation technique. Pathologic examination revealed absence of the medial elastic fiber of the aortic wall of the normal sinus of Valsalva. This result supports the preference of entire root replacement instead of patch repair of the affected sinus for the isolated aneurysm in 1 sinus of Valsalva in a patient with Marfan's syndrome.

A true aneurysm of posterior tibial artery.

True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman who suffered from a distal embolism in the left toes. The surgical intervention involved an aneurysmectomy and the interposition of the posterior tibial artery using the saphenous vein graft. She has been doing well 22 months after the operation.

Long-term follow-up of acute type B aortic dissection: ulcer-like projections in thrombosed false lumen play a role in late aortic events.

OBJECTIVE: Patients with Stanford type B dissection treated medically during the acute phase have a risk of surgery and aortic rupture during the chronic phase. We investigated the predictors for late aortic events by focusing on the false lumen status with computed tomography. METHODS: A total of 160 patients were enrolled in the study, with a mean follow-up interval of 44.6 ± 25.4 months. Patients were divided into 3 groups according to the false lumen status at the time of onset: group T, thrombosed in 49 patients (30.6%); group U, thrombosed with ulcer-like projections in 52 patients (32.5%); and group P, patent in 59 patients (36.9%). RESULTS: The mean aortic enlargement rate of groups U and P was greater than that of group T (0.40 ± 0.91 mm/month in group U, 0.44 ± 0.49 mm/month in group P, and -0.016 ± 0.23 mm/month in group T). The event-free rate in groups U and P was lower than in group T: 5-year event-free rates of 67.4% ± 8.2% in group U and 57.7% ± 10.9% in group P versus 95.0% ± 4.9% in group T (group T vs group U: P = .0011, group U vs group P: P = .96, group P vs group T: P = .0004). Cox regression analysis revealed that the false lumen status (patent or ulcer-like projections) (P = .029), maximum aortic diameter at onset (P < .0001), and patient age (P = .0069) were predictors of the late aortic events. CONCLUSIONS: In type B aortic dissection, a thrombosed false lumen with ulcer-like projections and a patent false lumen had an influence on late aortic dilation and late aortic events.

Isolated pulmonary stenosis in an elderly person: report of a case.

We report a rare case of isolated pulmonary stenosis in a 66-year-old woman. The patient underwent successful pulmonary valve replacement with a stentless bioprosthetic valve. The pulmonary valve was exposed with a longitudinal incision from the right ventricular outflow tract to the pulmonary trunk. The proximal posterior part of the bioprosthetic valve was anastomosed to the pulmonary valve annulus and the distal side was anastomosed to the pulmonary artery with an inclusion technique. The defect from the pulmonary artery to the right ventricular outflow tract was closed using an equine pericardium patch. The patient had an uneventful postoperative course.

Congenital quadricuspid aortic valve associated with severe regurgitation.

A 56-year-old man was referred because of severe aortic regurgitation. He had a quadricuspid aortic valve with a small accessory cusp between the right coronary and noncoronary cusps. The ostium of the right coronary artery was deviated toward the accessory cusp commissure. Aortic valve replacement was performed with a bioprosthesis. The resected cusps showed fibrotic thickening with calcification and fenestration.

Abdominal aortic aneurysm associated with horseshoe kidney.

The optimal approach to abdominal aortic aneurysm with horseshoe kidney is still debated. We describe a successful abdominal aortic aneurysm repair through a left retroperitoneal approach in a 77-year-old woman with a horseshoe kidney.

Acute dissection of the innominate artery: a case of report.

A 61-year-old man developed a ruptured innominate artery associated with localized acute dissection. The innominate artery was reconstructed with a bifurcated prosthetic graft without brain complication.

Aortic root replacement for destructive aortic valve endocarditis with left ventricular-aortic discontinuity.

BACKGROUND: Destructive aortic valve endocarditis causes the development of left ventricular-aortic discontinuity. Our experience of aortic root replacement in patients with the left ventricular-aortic discontinuity is presented. METHODS: Between 1999 and 2006, 8 patients (7 men, 1 woman) with left ventricular-aortic discontinuity underwent aortic root replacement in our institute. Their mean age was 56 years. Six patients were in New York Heart Association functional class III or higher. Four patients were diagnosed to have native valve endocarditis, and 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2 patients, aortic root replacements in 2). Radical débridement of the aortic root abscess was performed in all patients, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 2 patients. Fibrin glue saturated with antibiotics was applied into the cavity in 5 patients. Aortic root replacement was achieved with pulmonary autograft (Ross procedure) in 4 patients and stentless aortic root xenograft in 3. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary fashion. RESULTS: No patients died during hospitalization or follow-up. Freedom from major adverse cardiac events was noted in 67% of the patients at 5 years. CONCLUSIONS: An excellent outcome can be achieved by radical exclusion of abscess in the cavity, followed by root replacement with viable pulmonary autograft or flexible stentless aortic root xenograft in patients with left ventricular-aortic discontinuity.

Three cases of newly developed paraplegia after repairing type A acute aortic dissection.

Postoperative paraplegia after repairing type A acute aortic dissection has been rarely reported and the causes have not been clearly elucidated. We had three cases of newly developed paraplegia after repair of type A acute aortic dissection. In these cases, we speculated that some intercostal arteries were occluded by completely thrombosed false lumen with late onset of systemic hypotension, which might have reduced spinal cord perfusion followed by paraplegia.