Simple method for determining proper length of artificial chordae in mitral valve repair.

A simple method for determining the length of artificial chordae in mitral reconstructive operations is described. A small tourniquet is used for fine adjustment of the length of polytetrafluoroethylene stitches before tying them during leaking test. We have used this technique in 10 consecutive patients with anterior mitral leaflet prolapse since August 1992. Intraoperative transesophageal echocardiography revealed no or only trace mitral regurgitation after valve repair in all cases. This method minimized the time of determining the proper length of artificial chordae and achieved good results.

Severe hemolysis due to artificial chordae displacement.

Hemolytic anemia is a well-recognized complication of mechanical heart valve prosthesis but, as yet, has not been reported after mitral valve repair with chordal replacement. We report a case of severe hemolytic anemia after mitral valve repair with chordal replacement and Carpentier-Edwards annuloplasty ring insertion. Progressive prolapse of the anterior leaflet due to the artificial chordae being too long caused recurrent regurgitation which was responsible for the hemolysis. The patient also had idiopathic thrombocytopenic purpura, but successful second mitral valve repair was performed after high-dose gamma-globulin therapy.

Reconstruction of dilated aortic annulus using short tubular Dacron graft for aortic root replacement by aortic homograft--a solution for size mismatch.

To circumvent the problems associated with a dilated aortic annulus we first reduced the diameter of the annulus with a short section of Dacron graft and then implanted a smaller size homograft within the graft. This procedure was successfully performed for complete homograft aortic root replacement in a 25-year-old man with severe aortic insufficiency due to a dilated aortic annulus. The indication for homograft replacement can thus be widened, even to patients with a dilated aortic annulus.

Post-transfusion graft-versus-host disease following open heart surgery. Report of six cases.

Six cases of post-operative erythroderma after open heart surgery are described. About 10 days after seemingly uneventful recovery, all patients developed fever, erythroderma, liver enzyme elevation, pancytopenia, and an aplastic bone marrow. Their condition rapidly deteriorated, and they died within 20 days of the onset of symptoms. Skin biopsy specimens from two patients showed mild leukocytic infiltration in the epidermal basal layer and upper dermis. Immunostaining by the ABC method showed that most of these infiltrating cells were suppressor/cytotoxic T cells. HLA study of peripheral lymphocytes from two patients and their families revealed that the patients' HLA phenotypes were incompatible from their children's HLA findings. Y chromatin was present in the lymphocytes of the skin biopsy specimen of a female patient. Based on the clinical picture, skin biopsy, HLA study, and Y chromatin study, the authors strongly suspect post-transfusion GVHD as the etiology of postoperative erythroderma, although these patients lacked any known immunodeficiency.

[Occlusion of left coronary ostium involving aortic stenosis and insufficiency].

Aortic valve replacement combined with enlargement of the valvar ring by the Nicks method and coronary artery bypass grafting via the left internal thoracic artery were performed for an 11-year-old girl with occlusion of the left coronary ostium. The left coronary sinus was covered with membranous tissue, so the left coronary ostium was not found. Aortic valve replacement with 21 mm prosthetic valve was possible by enlarging the valvar ring. The internal thoracic artery which is expected to grow with development of the body was used as the graft.

[Mitral valve plasty for better long term results].

Between July 1991 and January 1995, 74 patients with pure mitral valve regurgitation (MR) underwent mitral valve plasty (MVP) at out institute. Our procedure includes chordal replacement of the anterior leaflet with PTFE sutures (42 patients). There were one hospital death (1.4%) and two late deaths (2.7%) in this series. Only 2 patients (2.7%) needed valve replacement after unsatisfactory repair during the same operation. Late postoperative doppler echocardiographic study (mean follow-up, 12.0 months) showed less than mild regurgitation in 66 patients (95.7%) of 69 patients who are alive. In April 1993 we decided to complete the repair with no or only trivial regurgitant flow by intraoperative transesophageal echodoppler study (TEE). The results have remarkably improved. Late postoperative echodoppler study revealed less than mild reguritant flow in all 49 patients having undergone mitral valve repair with no or trivial regurgitation by intraoperative TEE. It is clear than the TEE study has contributed to the better quality of mitral valve plasty, and we believe that it is important for better long term results to complete mitral valve plasty with no or only trivial regurgitant flow.

[A case report of the pectoralis major muscle flap in the successful management of severe mediastinal infection].

A severe, post-mediansternotomy, mediastinitis was treated with pectoral muscle flap method. About 10 days after CABG this patient had purulent discharge, high fever, and unstable sternum. Under a diagnosis of mediastinitis, wound irrigation and systemic administration with antibiotics began, but these managements were ineffective. Therefore, we closed the chest primarily by the pectoral muscle flap method. Successful primary closure of the chest was accomplished.

[Tricuspid valve replacement in the true annulus of Ebstein's anomaly without involvement of atrioventricular conduction disturbance].

Two female patients with Ebstein's anomaly, aged 12 and 45 years, underwent new procedures of tricuspid valve replacement in the true annulus without involvement of atrioventricular conduction disturbance. The first patient had a relatively small atrialized right ventricle. A Dacron patch was sutured on the atrialized portion from the right ventricular side. Buttress stitches were placed on the whole of the atrialized ventricle except at the part of the His' bundle. A porcine valve was sutured in the true annulus of the tricuspid valve and on the top of the patch. The second patient had a fairly large atrialized ventricle, and plication was made only in the inferior part of the atrialized ventricle form the coronary sinus. A porcine valve was sutured in the true tricuspid annulus except at the part of Koch's triangle, where the porcine valve was placed on the false annulus.

[Operative results of total replacement of the ascending aorta and aortic valve--characteristic difference between Bentall's and Cabrol's procedures].

From May 1979 to November 1991, 26 patients underwent total replacement of the ascending aorta and aortic valve. We employed 15 Bentall's procedure (group B) and 11 Cabrol's procedure (group C). There were no significant difference in age and etiology between the two groups. Inclusion technique was used in all patients. Compared group B with group C, both the operation time and the aortic cross-clamp time were significantly shorter in group C than in group B. (p < 0.05, p < 0.01 respectively). There were no operative death in group B and one in group C. There were two death in group B in later postoperative period. One was due to the anastomotic leakage at the distal site with infection, and the other was cardiac death caused by the infectious fistula between wrapping cavity and RA. The postoperative actuarial survival rate for group B at 12.8 years was 86.7% and that for group C at 5.1 years was 90.9%. The late complications such as coronary-graft anastmotic leakage or pseudoaneurysm, hematoma between the wrap and the graft and anastomotic leakage at the distal site were recognized more in group B. In group C no pseudoaneurysm were noted, but hematoma was noted in two patients. The rate of complications in late phase was significantly lower in group B (p < 0.05). Although as a procedure of total replacement of the ascending aorta and aortic valve both Bentall's and Cabrol's procedure represent satisfactory operative results, Cabrol's procedure has some advantages and fewer postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Axillo-iliac bypass grafting for reoperation of graft stenosis after aortic arch reconstruction of type B interruption of the aortic arch: two cases report].

Right axillo-iliac bypass grafting was performed in two females (10 and 14 years old) who had stenosis or obstruction of grafts after reconstruction of the aortic arch in type B interruption. The initial bypass operations were carried out at the age of 5 months and 5 years, with the use of a 5-mm EPTFE graft and a 10-mm Dacron graft. Nine years later, the EPTFE graft was completely obstructed, and the Dacron bypass has stenosis, kink and calcification. To minimize surgical invasion, axillo-iliac extra-anatomical bypass was employed in both patients. 8-mm or 10-mm Hemashield grafts were implanted between the right axillar artery and the right common iliac artery through the intrapleural-preperitoneal route, and favourable results were obtained in both patients. The axillo-iliac bypass is considered to be a beneficial conservative method of reoperation for stenosis after graft reconstruction of the aortic arch in the younger age patients.

[Clinical study of continuous warm blood cardioplegia with normothermic cardiopulmonary bypass in coronary artery bypass surgery].

This study was undertaken to determine whether continuous warm blood cardioplegia (CWBCP) could be acceptable as an alternative method for myocardial preservation in cardiac surgery. Between December 1991 and June 1993, 100 consecutive patients underwent coronary artery bypass surgery. Four patients who received terminal warm blood cardioplegia were excluded in this study. Fourty-eight patients (Group C) served as historical controls, and fourty-eight patients (Group W) from October 1992 to June 1993 served as a prospective, consecutive cohort for statistical comparison. Two groups varied in the types of myocardial protection and cardiopulmonary bypass (CPB) used: intermittent cold blood cardioplegia and moderate hypothermic CPB were used in Group C and CWBCP and normothermic CPB in Group W. The groups had similar number of bypass grafting, aortic cross-clamping time and CPB time. No patients was died. The prevalence of intraoperative cerebral infarction was equal in both groups (4.2%). The incidence of spontaneous defibrillation at cross-clamp removal was higher in Group W (85.4% versus 8.3%; p < 0.01). Less inotrope (dopamine) at 6 hours after operation was required in Group W (3.27 +/- 2.48 versus 4.78 +/- 2.99 micrograms/kg/min; p < 0.01). The intraoperative urgent use of the intraaortic balloon pump was noticeably less prevalent in Group W (0% versus 12.5%; p < 0.05). Group W patients were more likely to be hemodynamically stable after CPB discontinuing. Serum potassium levels during CPB was higher in Group W (max. 5.67 +/- 0.96 versus 4.39 +/- 0.50 mEq/l), so excessive potassium was eliminated using extracorporeal ultrafiltration. The major drawback of CWBCP was that continuous coronary perfusate occasionally obscured anastomosis site.(ABSTRACT TRUNCATED AT 250 WORDS)

The successful surgical repair of a left ventricular-right atrial communication and aneurysm of the mitral valve caused by infective endocarditis: report of a case.

We report herein the case of a 42-year-old man who developed a left ventricular-right atrial communication and aneurysm of the mitral valve caused by infective endocarditis, which was associated with aortic regurgitation. Based on the findings of congestive heart failure, prolongation of the PR interval, and the added threat of rupture of the mitral aneurysm, surgical treatment was decided upon as the best course of action. The aortic and mitral valves were replaced with prosthetic mechanical valves, and the septal communication was simultaneously closed with a patch. The patient's postoperative course was uneventful and he has been in good health since. Thus, we believe that aggressive surgical intervention for complicated lesions such as those seen in our patient may be life-saving, even in the presence of inflammatory signs.