Giant aneurysm of left circumflex artery branch with fistula to the coronary sinus: a case report.

BACKGROUND: Aneurysm of a coronary artery branch with a fistula is extremely rare. Here, we present a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus treated successfully with aneurysmectomy. CASE PRESENTATION: A 58-year-old woman was referred to our hospital due to an abnormal pericardial mass found by multidetector computed tomography. Imaging examination revealed a dilated left circumflex artery branch with a 30-mm aneurysm. Coronary angiography confirmed a left circumflex artery branch aneurysm with a fistula to the coronary sinus. As percutaneous occlusion of the aneurysm by catheterization was considered unsuccessful, the aneurysm was resected, and the fistula was occluded surgically with excellent outcome. Pathological examination suggested that congenital factors may have contributed to the development of the aneurysm. Computed tomography showed no recurrence of the aneurysm at 1-year postoperative follow-up. CONCLUSIONS: We presented a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus. This is the first report of the combination of a giant coronary artery branch aneurysm with a fistula to the coronary sinus. Surgical aneurysmectomy should be considered in such cases to avoid fatal aneurysmal complications.

The necessity of routine screening for deep vein thrombosis before surgery.

Background: Pulmonary embolism (PE) from deep venous thrombosis (DVT) can be a fatal postoperative complication. Preventive measures for venous thromboembolism (VTE) was evaluated in this hospital. Materials and methods: Preoperative DVT screening following surgery under general anesthesia in 2009-2016 was examined, and then, 217 patients diagnosed with DVT by preoperative leg-ultrasound (US) between 2014 and 2016 were retrospectively analyzed. Results: There were 24,826 operations under general anesthesia in the study period. Preoperative leg-US was performed in 5345 (21.5%) patients, and 648 (12.1% of patients, 2.6% of total operations) were diagnosed with DVT. In 2014-2016, 217 patients, which is 11.7% of patients undergoing leg-US, were diagnosed with DVT. DVT was found in the proximal veins (upper popliteal vein) in 86 (39.6%) patients. A total of 143 (62%) patients were considered to have organized thrombi, no patient developed pulmonary embolism, and 133 (58%) patients were discharged without follow-up examination for DVT. Ninety-six patients were evaluated for changes on leg-US, with no difference in the results with and without anticoagulant use. On multivariate logistic regression analysis, anticoagulants appeared effective for non-organized thrombi, higher D-dimer levels (≥10 µg/mL), or orthopedic surgery. Conclusion: Preoperative screening for DVT did not appear useful, and treatment of asymptomatic DVT was not always necessary.

[True Ascending Aortic Aneurysm Late after Total Arch Replacement].

An aortic aneurysm was incidentally diagnosed in a 75-year-old woman during a thorough examination for other diseases. She had a history of total arch replacement( TAR) for aortic arch aneurysm 17 years previously. Contrast-enhanced computed tomography( CT) revealed a proximal aortic aneurysm with a maximum diameter of 67 mm protruding to the lateral side. She was treated by elective ascending aortic replacement. The resected aneurysm was not a pseudoaneurysm, but a true aneurysm. The etiology of this aneurysm might be long-term hemodynamic stress from the left ventricle and inadequate blood pressure control in addition to the anatomical position of the proximal residual aorta after first surgery. Therefore, to prevent aneurysm formation, it is important to replace the ascending aorta as proximally as possible at first surgery and to continue strict postoperative blood pressure control.

[Suspended Ventricular Septal Defect Closure Due to Heparin Resistance;Report of a Case].

We present a case of heparin resistance whereby open heart surgery was discontinued. A 53-year-old woman who was diagnosed with ventricular septal defect and atrial septal defect was scheduled for intracardiac repair. However, after intravenous heparin (400 U kg-1) supplementation, the activated clotting time (ACT) increased only to seconds. The operation was discontinued because the addition of heparin( 200 U kg-1) did not show sufficient prolongation of ACT, fully indicative of heparin resistance. Additional antithrombin III concentrate was also ineffective. Postoperative study of the administration of heparin in vitro to the patient's serum showed the probability of transient heparin resistance arising from the stress of surgery.

Aortic root replacement for annuloaortic ectasia with a single coronary artery.

A single coronary artery, arising from the left sinus of Valsalva, associated with a bicuspid aortic valve and annuloaortic ectasia, is very rare. We report on a surgical case of bicuspid aortic valve regurgitation, annuloaortic ectasia, and dilation of the ascending aorta to the aortic arch in a patient with a single coronary artery. We successfully performed aortic root replacement with reimplantation of the single coronary artery and total arch replacement. The reimplantation of the coronary orifice required particular attention. Postoperative CT demonstrated the expected contours from the aortic annulus to the aortic arch with a patent implanted coronary artery.

[Midterm Outcomes of Root Replacement Using Homograft for Aortic Valve Infective Endocarditis].

From August 2003 to June 2013, 9 patients with aortic valve endocarditis underwent aortic root replacement using homografts which were harvested and preserved in our institute. The median patient age was 62 years (range 46~84) and 5 patients were men. Four cases were prosthetic valve infections. The in-hospital mortality was 0%. In 8 of 9 cases were evaluated on midterm outcomes. At a median of 52 months (range 19~156), overall survival was 100%, freedom from cardiovascular events was 87.5%. The peak aortic pressure gradient was 9.04 ± 4.2 mmHg. Aortic regurgitation was less than 2 of 4 in all cases.

[Full root replacement with a Freestyle bioprosthesis for prosthetic valve endocarditis complicated by aortic-root pseudoaneurysm after subcoronary technique; report of a case].

We report a surgical case of prosthetic valve endocarditis( PVE) after aortic valve replacement with a Freestyle stentless bioprosthesis, which was successfully treated with full root replacement using a Freestyle valve. A 80-year-old man underwent aortic valve replacement with a Freestyle stentless bioprosthesis, using subcoronary technique for aortic stenosis in 2004. Three years later he had late PVE, and we found the aortic-root pseudoaneurysm. Although homografts are the optimal for cases of severe aortic annular destruction, availability of these are limited in Japan. We chose a Freestyle valve with full root technique, which fitted well to the destroyed annulus. The postoperative course was uneventful. Freestyle stentless bioprosthesis can be useful option for PVE, meanwhile care should be taken to dead cavity between prosthesis and aortic wall in the subcoronary technique.

[On pump beating heart mitral and tricuspid valve annuloplasty via right mini thoracotomy approach in a patient who had undergone cardiac surgery 3 times].

The patient was an 84-year-old man. He had a history of 3-time median sternotomy with a functioning coronary bypass graft. Because of his dependence on inotropic agents caused by a progressing mitral and tricuspid valve insufficiency, we decided to perform surgery. To avoid heart damage and injury to the bypass graft by adhesiotomy, we performed on-pump beating heart mitral and tricuspid valve annuloplasty via right mini-thoracotomy approach. He was discharged 16 days after surgery. The on-pump beating heart valve repair via right mini-thoracotomy approach was useful in a selected case with multiple surgeries.

Giant saccular aneurysm of coronary arteriovenous fistula to the main pulmonary artery: intraoperative assessment by using fluorescent imaging.

Coronary arteriovenous fistulas (CAF) and coronary artery aneurysms (CAA) are uncommon, but their detection has recently increased. In this case we succeeded in identifying the residual shunt flow by using an intraoperative fluorescence imaging technique with indocyanine green after surgical treatment. The photodynamic eye imaging system is based on fluorescence of indocyanine green. This is the first report to identify residual shunt flow with such a giant coronary aneurysm by using fluorescence imaging, and the result indicates that this technique is useful for acceptance as one of the examinations to evaluate CAAs. Furthermore, it may be useful for the detection of shunt cases, such as congenital heart disease.

Active infective endocarditis: management and risk analysis of hospital death from 24 years' experience.

BACKGROUND: This study was performed to identify risk factors for hospital death in patients with acute and active infective endocarditis (AAIE) after surgical intervention. METHODS AND RESULTS: From 1980 to 2004, 94 patients underwent surgery for AAIE (age range, 3-77 years; 76% males). Congestive heart failure (CHF) was present in 44 patients, as well as vegetations in 64, septicemia in 16, abscesses in 17, and emboli in 22; 16 patients had prosthetic valve endocarditis. Streptococci were the most common bacteria (34 patients), followed by staphylococci (17 patients). Mechanical valves were selected for 73 patients and bioprosthetic valves for 16. Mitral valve plasty was performed in 4 patients. Aortic root or aorto-mitral discontinuity was repaired in 17 patients, including Manouguian's double valve replacement in 6 and aortic root replacement in 4. Overall hospital mortality was 15% (14 patients). Univariate analysis identified CHF (p=0.016), abscess (p=0.014), and prosthetic valve endocarditis (p=0.043) as risk factors. However, multivariate analysis only identified CHF (p=0.019) as an independent risk factor. CONCLUSION: In AAIE, early surgical intervention is advisable before the occurrence of complications such as root abscess and CHF, particularly before the onset of CHF.

Midterm results of Manouguian double valve replacement: comparison with standard double valve replacement.

OBJECTIVE: Surgical strategies for patients who have a small aortic annulus associated with a small mitral annulus remain controversial. The objective of this study was to assess the validity of the Manouguian procedure for double valve replacement with patch enlargement of the annuli. METHODS: We reviewed 57 consecutive patients who underwent double valve replacement for combined aortic and mitral disease between September 1991 and October 2000. Thirty patients underwent the Manouguian procedure with patch enlargement of the aortic and mitral annuli, and the other 27 patients had standard double valve replacement. The Manouguian procedure was selected for a small aortic annulus of less than 21 mm in diameter. The patients were followed for a median of 7.5 years. Results of echocardiography and the dobutamine stress test were compared postoperatively. RESULTS: Double valve replacement with the Manouguian procedure did not increase the early or midterm mortality because the survival (including operative death) at 8 years was 83% in the Manouguian group and 84% in the double valve replacement group (P = .82). The event-free rate at 8 years was 79% in the Manouguian group and 84% in the double valve replacement group (P = .6). The prostheses implanted at the aortic and mitral positions were smaller in the Manouguian group, even after annular enlargement. However, the transprosthetic gradient across the aortic valve evaluated by means of dobutamine stress echocardiography did not differ between the 2 groups, possibly because of a smaller body surface area in the Manouguian group. CONCLUSIONS: The Manouguian patch enlargement procedure is useful during double valve replacement when associated with the problem of small-valve annuli.