[A Case of Successful Surgery for Adult Partial Atrioventricular Septal Defect].

We report a case of a 55-year-old male who had been diagnosed with mitral regurgitation and atrial septal defect 5 years earlier. He was referred to our institution because of worsening of mitral regurgitation accompanied by exertional dyspnea. As an echocardiography showed atrioventricular valve regurgitation and ostium primum atrial septal defect, but without ventricular septal defect, he was diagnosed as having partial atrioventricular septal defect (pAVSD). An operation was performed through median sternotomy. The anterior atrioventricular leaflet had a cleft and thickening with calcification. Suturing the cleft could not control the regurgitation. Incomplete coaptation was seen at the edge of the anastomosis site of the cleft, where the severe calcification had been identified. A rough zone including a part of the chordae tendineae was sutured in order to compensate for the gap. The atrioventricular septal defect was closed with an autologous pericardial patch. He was discharged uneventfully on the 24th postoperative day and has been followed up without complications for 1.5 years.

Surgical Therapy for Patients with Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement.

Aortic stenosis (AS) is the most common valvular heart disease and is most frequently recognized among elderly people. Surgical aortic valve replacement (SAVR) is the most effective therapy, but its indication is sometimes difficult, and is impossible for high operative risk patients. Transcatheter aortic valve replacement (TAVR) was recently approved in Japan for high risk and inoperable patients with severe AS. TAVR is a less invasive method because it does not require a cardiopulmonary bypass and is associated with excellent surgical outcomes. In Western countries, the indication of TAVR has already been extended to moderate operative risk patients with severe AS, and is going to be further extended to low risk patients. The number of patients undergoing TAVR is increasing progressively, and there are effective alternative therapies for patients with severe AS. Selection of these surgical methods will be important in the near future. In regard to low operative risk patients especially, not only operative mortality, but also long-tern mortality and morbidity and quality of life should be taken into consideration. It is considered that some comorbidities in AS patients will be revealed to have an impact on surgical outcomes at the time when these surgical methods are selected. In this review, we examine end-stage renal disease on hemodialysis, functional tricuspid regurgitation, and sigmoid septum, and give an outline of what influence SAVR and TAVR have on the surgical outcomes of severe AS patients.

Impact of sarcopenia on long-term survival after cardiac surgery for end-stage renal disease patients.

BACKGROUND: The long-term mortality of end-stage renal disease (ESRD) patients is still unsatisfactory. Therefore, long-term risk assessments in ESRD patients undergoing cardiac surgery are needed. Recently, sarcopenia is major concern in cardiac surgery because of its association with poor long-term survival. However, the impact of sarcopenia on the long-term survival of ESRD patients undergoing cardiac surgery is not well understood. METHODS: Eighty-two ESRD patients who underwent elective cardiac surgery were enrolled. Sarcopenia was identified based on noncontrast abdominal computed tomography. The impact of preoperative and intraoperative factors on long-term survival was investigated. RESULTS: Forty-three patients (52%) were diagnosed with sarcopenia. The in-hospital mortality rate was 4.9%. The 5-year overall survival rate was 48%. The multivariate analyses revealed that STS score ≥ 4 (odds ratio, 6.0; confidence interval, 2.5-14.7; p < 0.01) and presence of sarcopenia (odds ratio, 2.4; confidence interval, 1.3-4.5; p = 0.03) were independent risk factors for overall survival. The 5-year survival rates of low-risk (Society of Thoracic Surgeons score of < 4) patients without sarcopenia, low-risk with sarcopenia, more than intermediate-risk (Society of Thoracic Surgeons score of ≥ 4) without sarcopenia, and more than intermediate-risk with sarcopenia groups were 80%, 51%, 50%, and 26%, respectively. CONCLUSIONS: Among the ESRD patients, the low risk without sarcopenia group showed an excellent long-term survival, in contrast to more than intermediate-risk patients with sarcopenia, who can expect poor long-term survival. Preoperative assessment of sarcopenia in addition to the surgical risk score can be useful in developing a therapeutic strategy.

[Arch aneurysm and ruptured innominate artery aneurysm with acute occlusion of trachea].

We reported on a case of 80-year-old woman who suffered from severe acute respiratory failure. A chest computed tomography (CT) revealed arch aneurysm and innominate artery pseudoaneurysm, which severely compressed main bronchus and trachea. After tracheal intubation in the emergency room, respiratory status improved rapidly. We immediately performed total arch replacement using deep hypothermia, circulatory arrest and the arch first technique. The postoperative course was uneventful, and stenosis of trachea resolved. Arch aneurysm associated with acute trachea occlusion is very rare and employing deep hypothermia, circulatory arrest and the arch first technique is useful for such atypical arch aneurysms.

Significant delayed aortic dilatation after tetralogy of Fallot repair: a case report.

BACKGROUND: Aortic dilatation may occur in some patients even after complete repair of tetralogy of Fallot (TOF). The progression rate of the aortic diameter is so slow, and the incidence of aortic dissection is so low that it is suspected that frequent imaging of the aorta may not be necessary. CASE PRESENTATION: We describe an asymptomatic 41-year-old man with hypertension in whom aortic dilatation was accidentally discovered 39 years after TOF repair. He underwent ambulatory follow-up without any difficulty for 21 years after the repair. Contrast-enhanced computed tomography revealed significant aortic dilatation (maximum diameter of 88 mm at the sinus of Valsalva), and echocardiography revealed severe aortic regurgitation, which seemed to progress during the last 18 years without any evaluation or follow-up. The Bentall procedure was successfully performed using a valved graft, under deep hypothermic circulatory arrest with antegrade cerebral perfusion, and his postoperative course was uneventful. Histopathological examination of ascending aorta specimens revealed severe cystic medial degeneration. CONCLUSIONS: Keeping in mind that a patient with rapid progression of the aortic dilatation after TOF repair exist, periodic follow-up for evaluation of the aorta is essential in patients with TOF.

Salvage surgery combined with descending aorta resection for lung cancer.

BACKGROUND: Recent retrospective studies have shown that salvage surgery can improve survival with acceptable adverse events, and this procedure has been adapted for lung cancer. However, there are no reports demonstrating the efficacy of salvage surgery combined with aortic resection. CASE PRESENTATION: A 73-year-old man had received definitive concurrent chemoradiotherapy (carboplatin/paclitaxel, 70 Gy) for lung cancer originated from the left upper lobe and infiltrating the thoracic aorta (cT4N1M0 stage IIIA). Although the tumor has shrunk significantly (ycT4N0M0 stage IIIA), radiation pneumonitis occurred. Due to the steroid therapy, radiation pneumonitis was relieved; however, re-enlargement of the primary tumor was observed during steroid tapering. Nonetheless, the lymphatic and distant metastases were controlled. Moreover, aortic invasion was localized to the periphery of the third branch, and the tumor was considered to be resectable. Intraoperatively, we observed macroscopic evidence of aortic invasion in the periphery of the third branch; thus, left upper lobectomy combined with descending aorta resection was performed under partial extracorporeal circulation. The patient is currently active without any recurrence 21 months post-surgery. CONCLUSIONS: No clear consensus exists regarding salvage surgery combined with aortic resection for primary lung cancer. However, we believe that this surgery may improve the survival of carefully selected patients.

Aortic valve replacement after coronary artery bypass grafting with the in situ right gastroepiploic artery to the occluded right coronary artery using a temporary vein graft for cardioplegia.

BACKGROUND: The operation of aortic valve replacement (AVR) after CABG is a technically challenging procedure in respect to dissection of living grafts from its surrounding tissue, myocardial protection, and so on, especially that procedure to patients with living in situ functional arterial grafts to occluded native coronary arteries has a special problem in regard to myocardial protection because myocardial blood supply originates from various arteries including the left internal thoracic artery (LITA), the right internal thoracic artery (RITA), and the right gastroepiploic artery (GEA); hence, adequate myocardial protection should be fastidiously considered. CASE PRESENTATION: A 68-year-old woman, who underwent CABG comprised of the in situ LITA to the LAD, the in situ GEA to the RCA, and the saphenous vein graft (SVG) to the obtuse marginal branch of the left circumflex artery (LCX) to the triple vessel coronary disease 9 years before, was referred to our hospital due to the aortic valve stenosis. CONCLUSION: We successfully underwent an aortic valve operation to a patient with a functioning LITA to the occluded left anterior descending artery and a GEA to the right coronary artery (RCA) by using a temporary vein graft to the RCA for the infusion of cardioplegic solution in addition to the conventional antegrade and retrograde cardioplegic infusions with ice slush topical cooling.

"Pouch Technique" Makes Proximal Anastomosis of Free Internal Thoracic Artery Graft to Ascending Aorta Easy and Safe in Coronary Artery Bypass Surgery.

PURPOSE: The proximal anastomosis of free right internal thoracic artery to ascending aorta is technically difficult when the caliber is not enough. METHODS: We incise the proximal stump of the graft longitudinally for 10 mm. One side of start point of longitudinal incision is sewn to the end point of incision by 7-0 polypropylene. The folded sideline (5 mm length) is then closed with a running suture, then formation of pouch like anastomotic end is accomplished. RESULTS: We used this technique in consecutive 34 patients who underwent coronary artery bypass surgery including revascularization to circumflex arteries. Postoperative angiography revealed 97% patency. It does not need another graft material like saphenous vein or radial artery, and possible not only in on pump surgery but also in off pump. CONCLUSION: This new "Pouch technique" will make it easy to use right internal thoracic artery as a free graft in coronary artery bypass surgery.

Adaptive immunity is severely impaired by open-heart surgery.

OBJECTIVE: The influence of open-heart surgery on antigen-specific immunity, also called adaptive immunity, remains to be clarified. We explored the effects of open-heart surgery on adaptive immunity. METHODS: In 8 consecutive adult patients undergoing elective cardiac surgery with cardiopulmonary bypass, we measured the T cell-response to purified protein derivative (PPD) antigen perioperatively. We separately measured the proliferation of T cells and the antigen presentation of antigen-presenting cells (APCs) using a cross-reaction system. RESULTS: T cell response to PPD antigen was severely impaired by open-heart surgery. Compared to preoperative values, T cell response to PPD antigen fell to 5.7 +/- 4.4% immediately after surgery, 4.5 +/- 3.2% on postoperative day (POD) 1, to 22.4 +/- 24.6% on POD 3 and to 50.1 +/- 34.3% on POD 7. T cell proliferation on POD1 decreased to 29 +/- 26%. APC antigen-presentation on POD 1 also decreased to 31 +/- 36%. CONCLUSIONS: Open-heart surgery impaired both T cell proliferation and the antigen-presentation. Such synergistic impairment severely impaired adaptive immunity. This impairment was both severer and longer than we anticipated based on previous studies using the response of T cells to lectin as a marker of cell-mediated immunity.

Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection.

OBJECTIVES: To identify the risk factors for mortality and establish improved treatment strategies in patients who have acute type A aortic dissection with coronary artery dissection. METHODS: From January 1994 through December 2011, we performed surgery in 516 patients with acute type A aortic dissection. We studied 75 (15%) of these patients who had coronary artery dissection. Myocardial ischaemia was present in 48 (64%) of the 75 patients. The culprit coronary artery was the right coronary artery (RCA) in 26 patients, the left coronary artery (LCA) in 19 and the RCA + LCA in 3. For coronary artery reconstruction, preoperative coronary stent placement was done in 7 patients (RCA, 4 and LCA, 3), aortic root replacement in 14, coronary artery bypass grafting in 23 and biological glue application in 28. The relationships of preoperative risk factors and coronary artery reconstruction procedure with in-hospital death and postoperative low cardiac output syndrome (LOS) were analysed using Fisher's exact test. RESULTS: Hospital death was 18/75 patients (24%), 16/48 (33%) among patients with ischaemia and 2/27 (7.4%) without ischaemia. The culprit lesion involved the RCA in 4/26 patients (15%), the LCA in 9/19 (47%) and the RCA + LCA in 3/3 (100%). Factors related to operative mortality were ischaemia (P = 0.019), LCA territory ischaemia (P = 0.003) and preoperative cardiopulmonary arrest (CPA) (P = 0.013). Postoperative LOS was less common in patients with coronary stent placement (P = 0.042). CONCLUSIONS: In patients who undergo surgery for acute type A dissection with coronary artery dissection, preoperative CPA and myocardial ischaemia (particularly LCA territory ischaemia) negatively affect survival outcomes. Early revascularization by coronary stent placement is effective in preventing postoperative LOS.

Surgical application for a prolapse of the anterior mitral leaflet by replacing artificial chordae with polytetrafluoroethylene grafts.

PURPOSE: There are an increasing number of reports concerning mitral valve repair by a reconstruction of the chordae tendinae using expanded polytetrafluoro-ethylene (PTFE) sutures. However, little information is available about extended application or results of this technique for an extended prolapse of the anterior mitral leaflets. METHODS: Between July 1991 and August 2003, 28 patients with moderate to severe mitral regurgitation as a result of a prolapse of anterior leaflets (age range, 15-73 years) underwent mitral valve repair by reconstruction of the artificial chordae with 4-CV expanded polytetrafluoroethylene sutures without a leaflet resection. Either Kay's suture technique or ring annuloplasty was also performed to correct annular dilatation in all patients. RESULTS: No operative death or late mortality was observed. The prolapsed segment, which was successfully repaired, was within 33% of the anterior mitral leaflet (AML) in 6 patients, from 33% to 50% in 5, from 50% to 99% in 11, and 100% in 6 patients. Before discharge, immediate postoperative echocardiography showed less than moderate mitral regurgitation in 28 of 28 patients. The follow-up, consisting of a clinical examination and serial echocardiograms, was complete in all cases and the mean follow-up period was 80.6 months (range, 12-146). There were two failures that required a reoperation because of a worsening mitral regurgitation and hemolytic anemia (elongation of anchored side of papillary muscle). The other two patients required mitral valve replacement due to a progressive regression of the left ventricular function, although the regurgitation worsened from a mild level to a moderate one. When the reoperated patients were excluded from the following data, the degree of mitral regurgitation, estimated by echocardiography performed at recent follow-up period, was none in 10 patients, trivial in 13 patients, and mild in 1 patient. In addition, the systolic and diastolic dimensions of the left ventricle decreased significantly (P < 0.01). CONCLUSIONS: The replacement of artificial chordae was not complicated and it seemed to help to preserve a good relationship among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae appears to be a promising procedure for the repair of all kinds of mitral lesions causing mitral regurgitation.

Impaired endothelial function of the umbilical artery after fetal cardiac bypass.

BACKGROUND: Recently, endothelial dysfunction as a result of fetal cardiac bypass has been reported. Here, the effect of fetal cardiac bypass on the endothelial function of the umbilical artery was investigated by a tension study. METHODS: Fourteen fetal lambs were divided into a control group (n = 7) and a pump group (n = 7). In the pump group, cardiac bypass was maintained for 30 minutes using a low-volume priming circuit with a centrifugal pump. Hemodynamic measurements and blood gas analyses were performed before, during, and 30 and 60 minutes after cardiac bypass. The umbilical artery was harvested 60 minutes after cessation of cardiac bypass. Endothelium-dependent relaxation (bradykinin, calcium ionophore A23187) and endothelium-independent relaxation (sodium nitroprusside) were measured after smooth muscle contraction by 60 mmol/L potassium or serotonin and compared between the two groups. RESULTS: The umbilical artery flow and aortic pressure of the fetus were significantly decreased at 30 and 60 minutes after cardiac bypass. Hypoxia and hypercapnia were recognized during and after cardiac bypass. Metabolic acidosis progressed during and after cardiac bypass. Endothelium-dependent relaxation was impaired in the pump group compared with the control group (bradykinin: 43.6% +/- 6.4% in the control group, 18.9% +/- 2.5% in the pump group, p < 0.01; A23187: 37.8% +/- 4.6% in the control group, 19.6% +/- 3.9% in the pump group, p < 0.01). Meanwhile, endothelium-independent relaxation was preserved in both groups. CONCLUSIONS: Fetal cardiac bypass caused endothelial dysfunction of the umbilical artery and hemodynamic deterioration as a result of metabolic acidosis. Prevention of endothelial damage and metabolic acidosis could be the main target for successful fetal cardiac surgery.