[Giant Coronary Artery Aneurysm in the Main Trunk of the Coronary Artery].

The case is a 76-year-old woman. She was admitted to the hospital because of chest and back pain. Coronary angiography revealed a 62-mm giant coronary artery aneurysm originating from the left main trunk( LMT), and urgent surgery was performed. Coronary artery-pulmonary artery fistula along with coronary artery aneurysm was completely removed by surgery. In this case, the reconstruction strategy for the LMT was crucial. The aneurysm wall was completely resected, allowing the coronary artery to return to its original course, and the length of the LMT defect was <2 cm. We determined that anatomical reconstruction of the LMT was optimal and succeeded in replacing a short great saphenous vein corresponding to the length of the defect. The patient was discharged without any complications.

[New Intracoronary Shunt Cannula in Off-pump Coronary Artery Bypass Grafting].

In off-pump coronary artery bypass grafting(OPCAB), a bloodless operative field has great influence on the quality of anastomosis. In addition, maintenance of distal coronary flow during anastomosis stabilizes hemodynamics. We introduced a new intracoronary shunt cannula, Mini Shunt Pro (MSP). MSP adopts the step-tip, which allows easy insertion and reduces the risk of intimal injury. The distal and proximal sides of the tips of MSP are 0.25 mm different in diameter, which improves its fitness to the coronary artery and enhances a bloodless operative field. This new shunt cannula is considered to be safe and useful for high-quality anastomosis in OPCAB.

Impact of novel intraoperative evaluation for mitral valve regurgitation: the retrograde cardio-protective beating test.

PURPOSE: The saline injection test is commonly employed during mitral valvuloplasty. However, discrepancies in regurgitation between the naked eye findings during the saline injection test and the postoperative echocardiographic findings have been noted. Here, we describe the new retrograde cardio-protective beating test (RC-beating test) which allows direct transatrial evaluation of the valve in the fully loaded, beating heart under cross-clamping by means of the retrograde perfusion of warm oxygenated blood into the coronary sinus. METHODS: From January 2006 to June 2012, 63 patients (mean age, 59 ± 15 years) with degenerative mitral valve regurgitation underwent mitral valve repair with application of this novel evaluation. RESULTS: In 20 of the 63 patients (31.8%), minor residual leaks that were not remarkable in the saline injection test were detected during the RC-beating test and were completely corrected. Almost all patients (n = 61, 96.8%) revealed no mitral regurgitation on intraoperative transesophageal echocardiography. The results of the RC-beating test were satisfactory, and discrepancies were not recognized at all between this evaluation and the postoperative echocardiographic findings. The ultrastructure of the mitochondria showed significant myocardial preservation. CONCLUSION: The RC-beating test is a simpler and more accurate evaluation for mitral valve repair than the saline injection test. This novel evaluation enables a safe and more complete mitral valve repair.

[Mitral Valvuloplasty of Infective Endocarditis During Pregnancy].

This report describes a case in which we treated a patient who developed infective endocarditis in the mitral valve at 28 weeks' gestation. The condition was resolved by performing mitral valvuloplasty 2 days after an emergency cesarean section. Although the patient was in a relatively stable period at 32 weeks' gestation, the mother had an extremely high risk of embolism;thus, emergency surgery was required. We believe that an accurate diagnosis in a timely manner and a valvuloplasty shortly after cesarean section saved the life of the mother and child.

[Intraoperative evaluation for residual mitral valve regurgitation; usefulness of the retrograde cardioprotective beating test].

Intraoperative evaluation is important for successful mitral valve plasty (MVP). We performed a saline injection test and a retrograde cardioprotective beating test (RC-beating test) for intraoperative evaluation. The concept of the RC- beating test is evaluation of residual mitral valve regurgitation( MR) under cardiac beating. A 66-year-old man with severe MR underwent MVP. The P3 chorda was ruptured and we performed quadrangular resection. The saline injection test showed trivial regurgitation. We then performed the RC-beating test and it revealed severe leakage from the posterior commissure(PC). Since the PC had a sclerotic change, another quadrangular resection was performed. Moreover,as the anterior leaflet( A3) was slightly elongated, the region was resected in an obtuse-angled triangle shape and repaired by suturing the edges. The final RC-beating test showed no residual leakage. The RC-beating test is useful for detecting residual mitral valve leakage.

[Neuroleptic malignant syndrome after cardiac surgery].

A 64-year-old man without any psychiatric disease, including Parkinson's disease underwent aortic valve replacement and mitral valve replacement for rheumatic valvular disease. One day after the cardiac surgery, he developed hyperthermina, muscle rigidity, coma and delirium, and his serum creatine kinase (CK) level was elevated. In spite of his negative brain computed tomography(CT), his consciousness remained unclear. He had received diazepam, flunitrazepam and buprenorphine after the cardiac surgery because of his hyper-reactivity. Although these drugs were not typical antipsychotics' causing neuroleptic malignant syndrome (NMS), NMS was strongly suspected because of his clinical appearance. Dantrolene was administered in a dose of 60 mg per day and he recovered consciousness and his CK level began to decrease. We reported a case of neuroleptic malignant syndrome after cardiac surgery.

[Aortic valve surgery in a patient with cold agglutinin disease; effectiveness of continuous retrograde cardioplegia].

A 76-year-old female was hospitalized because of congestive heart failure and anemia. A thorough examination led to a diagnosis of severe aortic stenosis and cold agglutinin disease. The critical temperature for hemagglutination was 27 °C, which caused particular problems with regard to the myocardial protection temperature during surgery. Aortic valve replacement was performed safely by increasing the normal myocardial protection temperature from 15 °C to 32 °C and using 3 times the normal volume of cardioplagic fluid. As a result of strict perioperative thermal management, the operation was completed without any complications.

Evaluation of gastroepiploic arterial grafts to right coronary artery using transit-time flow measurement.

OBJECTIVES: The objective of this study was to analyse the relationship between the intraoperative transit-time flow measurement (TTFM) parameter values and the postoperative angiographic results of gastroepiploic arterial (GEA) grafts to the right coronary artery (RCA). We investigated whether the intraoperative TTFM parameter values are reliable indicators of early patency in GEA grafts to the RCA. METHODS: Patients undergoing off-pump coronary artery bypass surgery with GEA grafts were included in this study. Eighty-three GEA grafts were individually anastomosed and examined by angiography 1 week after surgery. The quality of each graft was graded using FitzGibbon grading (Study 1) and graft-flow grading (Study 2). RESULTS: Study 1: Seventy-two grafts were determined as Grade A and 11 as Grades B or O. There were no significant differences in the average of mean graft flow (MGF), pulsatility index or diastolic filling percentage between Grade A and Grades B or O grafts. Study 2: Sixty-two grafts were graded as good-graft dominant, 16 as bidirectional and 5 as occlusion including string. The average of the MGF, pulsatility index and diastolic filling percentage in the grafts graded as bidirectional and occlusion including string were not significantly different from those of grafts graded as good-graft dominant. CONCLUSIONS: Previously reported cut-off values for intraoperative TTFM parameters could not be adapted for the early patency of GEA grafts to the RCA. However, the smoothness of the graft-flow curve may be a reliable predictor of postoperative graft patency.

Stress echocardiographic assessment of mitral valve function repaired using rough-zone trimming.

BACKGROUND: We invented novel mitral valve repair technique; rough-zone trimming procedure (RZT) for anterior mitral valve prolapse. Prolapse site was resected in obtuse triangle shape and sutured edges to creates deep coaptation and improves regurgitation. Though it is simple and reproducible technique, functional mitral stenosis is a risk. Valve function and hemodynamics were investigated using dobutamine stress echocardiography (DSE) in patients after mitral valve repair using RZT. METHODS: Patients underwent RZT for the anterior mitral valve (AML, n = 10), quadrangular resection (QR) of the posterior mitral valve (PML; n = 4), RZT + QR of bileaflet valves (bileaflet; n = 4) and healthy individuals (control; n = 10) and were assessed by DSE (doses up to 20 µg/Kg/min). Echocardiographic data including mitral valve area (MVA), mitral valve mean pressure gradient (MVmeanPG), and systolic pulmonary artery pressure (sPAP) were measured at rest and at peak stress. RESULTS: Rest/stress MVA (cm(2)), MVmeanPG (mmHg) and sPAP (mmHg) were 2.8 ± 0.4 and 3.4 ± 0.3, 3.3 ± 1.1 and 7.4 ± 4.1, and 25.7 ± 4.7and 49.1 ± 4.1, respectively, in the AML group. Dobutamine stress increased all parameters but not to pathological levels. The results were similar to those of the other groups after mitral valve repair, whereas MVA was larger and MVmeanPG was lower in the control than in the AML group. CONCLUSIONS: Valve repair using RZT does not pathologically obstruct the mitral valve, either at baseline or during dobutamine stress, and does not affect valve hemodynamics and reserve.

New parameter of the right gastroepiploic arterial graft using the power spectral analysis device named MemCalc soft.

OBJECTIVES: Transit-time flow measurement (TTFM) parameters such as mean graft flow (MGF, ml/min), pulsatility index (PI) and diastolic filling (DF, %) have been extensively researched for internal mammary arterial or saphenous vein grafts. In our experience of using the right gastroepiploic arterial (GEA) graft for right coronary artery (RCA) grafting, we observed unique GEA graft flow waveforms. We analysed the GEA graft flow waveforms for their effectiveness in determining GEA graft patency by power spectral analysis. METHODS: Forty-five patients underwent off-pump coronary artery bypass using the GEA graft for RCA grafting individually. The means of intraoperative MGF, PI and DF were compared between patent and non-patent grafts, postoperatively. Furthermore, the GEA flow data were output and analysed using power spectral analysis. RESULTS: Forty grafts were 'patent' and five were 'non-patent'. There were no significant differences in the mean TTFM parameters between the patent and non-patent grafts (MGF: 22 vs 8 ml/min, respectively, P = 0.068; PI: 3.5 vs 6.5, respectively, P = 0.155; DF: 63 vs 53%, respectively, P = 0.237). Results of the power spectral analysis presented clear differences; the power spectral density (PSD) of patent grafts presented high peaks at frequency levels of 1, 2 and 3 Hz, and the non-patent graft PSD presented high peaks that were not limited to these frequencies. The PSD had a sensitivity and specificity of 80 and 87.5%, respectively. CONCLUSIONS: Power spectral analysis of the GEA graft flow is useful to distinguish between non-patent and patent grafts intraoperatively. This should be used as a fourth parameter along with MGF, PI and DF.

Acute dilatation of the ascending aorta and aortic valve regurgitation in Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is a recently recognized connective tissue disorder caused by mutations of the transforming growth factor (TGF)-ß receptors. It is an autosomal dominant syndrome characterized by the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula or cleft palate. We treated an 18-year-old woman with a 100-mm-diameter aortic root aneurysm and severe aortic valve regurgitation. She underwent urgent aortic root replacement and bioprosthetic valve implantation. LDS was diagnosed by postoperative genetic screening results. Histopathologic examination of the aortic wall showed diffuse degeneration and elastin fragmentation in the media.

Novel intraoperative evaluation for mitral valve regurgitation: retrograde cardioprotective beating test.

In mitral valvuloplasty, the saline injection test is commonly employed. However, discrepancies in regurgitation between the naked eye findings during the saline injection test and the postoperative echocardiographical findings are noted. Here, we describe a technique that allows direct transatrial evaluation of the valve in the fully loaded, beating heart without the risks of air embolism. Physiological systolic mitral valve movement is reproduced under aortic cross-clamping. This novel evaluation enables a complete and safe mitral valve repair.

Endovascular stent-grafting of anastomotic pseudoaneurysms following thoracic aortic surgery.

PURPOSE: Anastomotic pseudoaneurysm is a rare but life-threatening complication after thoracic aortic surgery. Endovascular stent-grafting is a less invasive treatment for thoracic aortic aneurysm; however, its clinical usefulness for anastomotic pseudoaneurysms following thoracic aortic surgery is unclear. METHODS: A series of 12 anastomotic pseudoaneurysms in 10 patients, which occurred following thoracic aortic surgery, underwent endovascular stent-grafting in our university hospital. Eight emergent endovascular stent-grafting cases were included in this study. A hand-made stent-graft, reconstructed by suturing graft material to an endoskeleton of modified Gianturco Z stents, was used in all cases. RESULTS: The delivery success rate was 91.7%, and the hospital mortality rate was 25.0%. Two cases were converted to open surgery during the postoperative phase because of a type I endoleak. Complete absorption or shrinkage of the anastomotic pseudoaneurysm was observed in seven of nine cases. CONCLUSION: Endovascular stent-grafting for patients with anastomotic pseudoaneurysms of the thoracic aorta following thoracic aortic surgery has become a possible optimal treatment. However, long-term outcome remains unclear, and periodical follow-up is required.

Total arch replacement with endarterectomy of the ascending aorta in a patient with aortic arch aneurysm and porcelain aorta.

We describe total arch replacement for aortic arch aneurysm with a severely calcified ("porcelain") aorta. Cardiovascular surgery is challenging under such conditions because the calcified plate interferes with clamping, incising, and suturing of the aorta. We performed this surgery under hypothermic circulatory arrest with antegrade cerebral perfusion. Calcification manifested particularly in the ascending aorta and prevented the use of a needle. We exfoliated the calcified intimal plate using an elevator designed for hand surgery, and then covered both the inner and outer sides of the endarterectomized aorta with a strip of bovine pericardium to reinforce the anastomotic region and cover the rough surface. No complications developed during or after surgery.