[Cardiac Failure Developing Eleven Years after Coronary Artery Bypass Grafting;Report of a Case].

We report a rare case of cardiac failure for intrapericardial hematoma 11 years after coronary artery bypass grafting. A 59-year-old man was admitted to our hospital with cardiac tamponade. Echocardiography and computed tomography scan showed severe compression of the left ventricle(LV) by a large mass sized about 5×8 cm. Coronary angiography showed total occlusion at circumflex branch (Cx) #11. The mass was diagnosed with intrapericardial hematoma. We performed removal of hematoma in the pericardial cavity, and removed hematoma had 126 g. Considering that the patient had suffered from diabetes mellitus, the localized collection of the hematoma might be explained by possible slow oozing from LV free wall rupture after asymptomatic myocardial infarction at Cx area.

[Surgical treatment of innominate artery aneurysm using temporary bypass to prevent cerebral ischemia].

A 69-year-old woman had an innominate artery aneurysm that was adjacent to the right common carotid artery and the right subclavian artery. The patient had a dominant right vertebral artery and an underdeveloped circle of Willis. At surgery, the proximal site of the innominate artery, the right common carotid artery and the right subclavian artery were clamped with the temporary bypass between the ascending aorta and the distal site of the right brachial artery for maintaining the blood flow to the brain. The innominate artery aneurysm was resected, and a woven Dacron Y-shaped graft, 14×7 mm in diameter, was used for reconstructing the innominate artery, the right subclavian artery and the right common carotid artery. The postoperative course was uneventful and there was no postoperative neurological deficit. Temporary bypass for maintaining cerebral perfusion was useful in preventing cerebral ischemia.

[Infective endocarditis].

Streptococcus species has been most common causative micro-organism in infective endocarditis, but the rate of Staphylococcus species increased lately, particularly the increase of methicilline resistance Staphylococcus was issue. We advocate early surgical intervention in cases with infective endocarditis involved congestive heart failure, resistance of antibiotics and/or embolism. In mitral valve endocarditis, many surgeon have tried valve plasty, the result has been improved. In case with prosthetic valve endocarditis, particularly involved annular abscess, preoperative worse condition, the necessity of complicated surgical technique, and the recurrence of infection resulted in poor outcomes. We strongly advocate earlier surgical intervention and wish easy access and availability of homograft.

Management of acute pulmonary embolism after acute aortic dissection surgery.

Acute aortic dissection (AAD) continues to be associated with high mortality and morbidity. Pulmonary embolism is also a life-threatening disease. The treatment of these life-threatening diseases remains controversial in case complications arise. Thrombolytic therapy and intensive treatment would be needed to manage these fatal diseases. A 49-year-old man with progressive back pain was admitted to our hospital. Computed tomography (CT) scan revealed type A AAD. Emergency operation for hemiarch replacement was performed. Two weeks postoperatively, the patient's oxygenation worsened and his d-dimer levels elevated. CT scan revealed a massive thrombus in the bilateral pulmonary arteries. Intensive anticoagulation therapy was started immediately. On postoperative day 27, the patient was weaned from mechanical ventilation, but the false lumen with thrombus was recanalized again. The patient was discharged on postoperative day 75 without resulting in major complications for aortic dissection. The diagnosis of pulmonary embolism concomitant with AAD is difficult. The treatment of pulmonary embolism after AAD is controversial. Our strategy seems to be suitable for acute pulmonary embolism that occurs during the treatment of AAD. ˂Learning objective: The diagnosis of pulmonary embolism concomitant with acute aortic dissection (AAD) is difficult. The treatment of pulmonary embolism after AAD is controversial. Investigating factor XIII levels might help in the early detection of pulmonary embolism.>.

A technique for the prevention of hoarseness during surgery for distal aortic arch aneurysm.

Hoarseness occurs frequently after surgery to repair distal aortic arch aneurysms when using only a median sternotomy approach. We describe a useful technique which protects the left recurrent laryngeal nerve during this procedure and reduces the incidence of postoperative hoarseness.

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.

Long-term assessment of mitral valve reconstruction with resection of the leaflets: triangular and quadrangular resection.

BACKGROUND: The procedure of quadrangular resection and suture for prolapsed posterior leaflet of the mitral valve is a reliable and reproducible method that achieves excellent long-term results. However, triangular resection and suture of a prolapsed anterior leaflet is not widely supported and different techniques have been advocated. The aim of this study was to review our experience of mitral valve repair in which resection of the anterior and/or posterior leaflets was performed. METHODS: Between October 1991 and September 2003, 105 patients with mitral regurgitation underwent mitral valve reconstruction with leaflet resection, including 55 patients with quadrangular resection of the posterior leaflet (P), 32 patients with triangular resection of the anterior leaflet (A), and 18 patients with resection of both leaflets (A+P). RESULTS: The mean follow-up period was 63.6 (1 to 139) months. Reoperation was required in 2 patients, each after resection of the anterior or posterior leaflet. The freedom from reoperation rates at 10 years in 93% +/- 5% of patients after triangular resection of the anterior leaflet, 96% +/- 3% after quadrangular resection of the posterior leaflet, and 100% after resection of both leaflets. There were no significant differences of survival or risk of reoperation among these three groups. The postoperative mitral valve area was significantly smaller than the preoperative area in all three groups, but remained large enough (A: 2.84 +/- 1.07; P: 2.6 +/- 0.87; A+P: 3.09 +/- 1.20 cm2) for adequate valve function. CONCLUSIONS: Triangular resection of a prolapsed anterior mitral leaflet is a reliable, reproducible, and durable procedure, like quadrangular resection of a prolapsed posterior leaflet.