Papillary muscle sandwich plasty for the treatment of functional mitral valve regurgitation.

We evaluated the availability of original "sandwich plasty" for the treatment of functional mitral regurgitation (FMR) associated with ischemic heart disease (IHD) and aortic valve disease (AVD). Forty-three patients were reviewed, including 27 IHD patients and 16 AVD patients. Preoperatively severe FMR was detected in 14 patients, moderate FMR in 26, and mild FMR in 3. The papillary muscle heads of anterior leaflets and posterior leaflets were approximated using Teflon-pledgeted 3-0 Ticron sutures at anterolateral and posteromedial commissural portions. After surgery, residual moderate FMR was observed in 1 patient and mild FMR in 3 patients. Tenting height of the mitral valve significantly decreased. FMR free rates 2 years after surgery were 93% among IHD patients and 83% in AVD patients. "Sandwich plasty" was simple and effective for the treatment of functional FMR caused by tethering effects due to left ventricular dilatation.

[Swan-Ganz catheter (pulmonary artery catheter)].

Swan-Ganz catheter (SGC : pulmonary artery catheter) was introduced in clinical use by Swan HJ and Ganz W in 1970. Since then, the catheter has been used in many kinds of clinical fields, such as critical care medicine, cardiovascular surgery, anesthesia, and cardiology, because of its useful functions. SGC can easily advance into the pulmonary artery with its flow-directed balloon. The central venous pressure (CVP), the pulmonary artery pressure (PAP), and the pulmonary capillary wedge pressure (PCWP) can be measured, and cardiac output is obtained by thermodilution method. These days, SGC also has continuous cardiac output measurement system and mixed venous blood oxygen saturation monitoring system. Continuous cardiac output system automatically works by heating blood in the right atrium and ventricle with thermal filament periodically. Although SGC gives full diagnostic and therapeutic information of critically ill patients or cardiac surgical patients, all of the patients can not survive their tough critical clinical situation struggling with complications. Therefore, SGC has to be applied to the patients after thorough consideration whether the patients receive benefit of the catheter or not. Furthermore, the data obtained from SGC must be carefully interpreted to manage the patients.

Septal-superior exposure in mitral valve surgery with radiofrequency ablation.

BACKGROUND: We review the results of surgical radiofrequency ablation of both atria in patients of mitral valve disease approached by septal-superior exposure and discuss the availability of this approach. METHODS: Eighteen patients with a mean age of 65 years were included in this study. Thirteen patients had mitral valve regurgitation predominantly and five had mitral valve stenosis. Eleven patients underwent mitral valve plasty and valve replacement was carried out in seven. All ablation lesions were created on both atria using radiofrequency energy delivered by a unipolar malleable radiofrequency ablation catheter with seven electrodes at a minimum temperature of 80-85 degrees C for a period of 2 min. RESULTS: At the time of discharge, 14 patients were showed normal sinus rhythm and one patient remained in AF. The other three patients were free from atrial fibrillation; however, they received dual-mode, dual-pacing, dual-sensing pacemaker implantation because of bradycardia during the early postoperative phase. At a mean time of 7 months after surgery, all patients were free from atrial fibrillation; 13 patients showed normal sinus rhythm and five patients received dual-mode, dual-pacing, dual-sensing pacemakers. CONCLUSION: Septal-superior exposure provides an excellent operative view both for mitral valve surgery and for radiofrequency ablation. However, this exposure has not been considered a first-line approach because of the high rate of pacemaker implantation.

Papillary muscle head approximation for the treatment of mitral valve regurgitation combined with aortic valve disease.

We initiated an original papillary muscle head approximation procedure, commonly known as Sandwich plasty, for the treatment of ischemic mitral regurgitation (MR). In this study, we evaluated the appropriateness of this procedure for functional MR associated with aortic valve disease. Fifteen patients who had undergone Sandwich plasty combined with aortic valve surgery were included in this study. The mean age of the patients was 69 years. Predominant aortic valve diseases were regurgitation in 8 patients and stenosis in 7 patients. Aortic valve replacement was performed in 14 patients and David surgery in one. The mitral valve was approached through the aortic annulus in 9 patients (the transaortic group). Six other patients with mitral valve annulus of 30 mm or larger underwent concomitant mitral ring-annuloplasty through a left atrial incision (the LA group). The tenting height of the mitral valve and left ventricle diastolic diameter significantly decreased after surgery in both groups. After surgery, residual moderate or mild MR was detected in two patients in the transaortic group. In the LA group, residual mitral regurgitation was not detected. In the follow-up study, prominent MR occurred in two patients in the transaortic group. The MR free rate two years after surgery was 83% in the total patient population. Sandwich plasty was simple and effective in the treatment of functional mitral regurgitation combined with aortic valve surgery. A transaortic approach is effective in obviating a separate left atriotomy and reducing operation time.

Effects of original crystalloid cardioplegia followed by additional blood cardioplegia: treatments for prolonged cardiac arrest.

PURPOSE: The efficacy of combination treatment of original cold crystalloid cardioplegia (SHA solution; St. Thomas + Histidine + ATP + oxygen) and additional blood cardioplegia was studied in patients who required cardiac arrest time of 120 minutes or longer. METHODS: One hundred and thirty-six patients were included in this study. Patients were divided into two groups according to the cardiac arrest time: S group (cardiac arrest time: 120-149 minutes, n = 81); L group (150-180 minutes, n = 55). Just after cross-clamping of the ascending aorta, 800 ml of SHA solution was infused in an antegrade fashion. Cold-blood cardioplegia was initiated after two hours of cardiac arrest. RESULTS: Six (4%) of the 136 patients died after surgery, 3 in each group. Two critical patients with ischemic cardiomyopathy died of cardiac failure after coronary artery bypass grafting (CABG), and 4 died of noncardiac morbidity. The mean value of postoperative maximum creatine phosphokinase-MB (CPK-MB) in dead patients was 47 IU/L in the S group and 75 IU/L in the L group. The peak CPK-MB values exceeded 100 IU/L in one out of 6 patients who died after surgery. CONCLUSIONS: Combination treatment using original SHA solution and additional blood cardioplegia was effective in patients who required prolonged cardiac arrest.

Surgical treatments for infective endocarditis involving valve annulus.

OBJECTIVE: The early and late results of infective endocarditis (IE) with annular involvement were studied by focusing on surgical findings and operative procedures. MATERIALS AND METHODS: Fifteen adult patients with a mean age of 56 years were reviewed. Eight had native valve endocarditis (NVE), and 7 had prosthetic valve endocarditis (PVE). The diseased valve was mitral in 6 patients, aortic in 8, and mitral plus aortic in 1. Twelve patients were operated on during the active phase of IE. Enterococcus, Staphyrococcus, Streptococcus, and Stenotrophomonaus Maltophilia were predominant in bacterial examination. The mean follow-up period was 37 months. RESULTS: Active vegetation was observed in 63% of total patients. In NVE patients, valve replacement was performed in all 8 after complete debridement and annular patch reconstruction. One patient with hemodialysis died of heart failure. In PVE patients, valve deficiency was observed in all and active perivalvular abscess in 4. Conventional valve replacement was performed in 4 patients, and 3 of them died after surgery. Three patients who underwent aortic root translocation or Ross procedure survived. The hospital mortality of NVE and PVE surgery was 3% and 43%, respectively. There were no significant correlations between operative results and perioperative factors. During the follow-up period, late recurrent endocarditis did not occur, and one patient died of noncardiac diseases. CONCLUSION: For NVE, good operative results were obtained after complete resection of infected valve annulus and valve replacement. For PVE, new surgical treatments, such as the translocation method or Ross procedure, should be induced for further improvement of surgical results.

Original papillary muscle sandwich plasty for ischemic mitral regurgitation.

BACKGROUND: Mitral valve plasty for functional ischemic mitral regurgitation (MR) is still a controversial procedure. METHODS AND RESULTS: The present study was a review of 23 patients who underwent an original technique known as "papillary muscle sandwich plasty" in which the mitral valve is approached via either the left atrium or left ventricle. The heads of the papillary muscles of the anterior leaflet and leaflets are plicated using Teflon-pledgeted 3-0 Ticron sutures in both the anterolateral and posteromedial commissural portions. Postoperative residual mild MR occurred in 1 patient (4%), but moderate or severe MR was not observed. In the follow-up study, prominent MR occurred in 1 patients and the MR-free rate at 2 years after surgery was 93%. Late cardiac death was significantly (P<0.05) fewer in patients without prominent MR than that in patients with MR. CONCLUSIONS: "Sandwich plasty" is an effective technique for patients requiring left ventricular plasty and may improve the prognosis of ischemic heart failure.

Combined surgery for ischemic cardiomyopathy: report of a case.

A 65-year-old female with catecholamine-dependent ischemic cardiomyopathy was admitted to our hospital. Preoperative examination revealed severe triple vessel coronary artery disease, severe mitral valve regurgitation and left ventricular (LV) dilatation associated with low ejection fraction. Coronary artery bypass grafting with four distal anastomoses, mitral valve plasty using original papillary muscle application method, LV volume reduction using overlapping method and biventricular pacing were performed. Postoperative course was uneventful and quality of life at 2 years after surgery was good. Active combined surgery has the possibility of improving the outcome of patients with severe ischemic cardiomyopathy.

Progression of abdominal aortic aneurysm after endovascular stent-grafting in a patient with Behçet's disease: report of a case.

A 53-year-old man with Behçet's disease was admitted to our hospital for investigation of back and lower abdominal pain. Computed tomography (CT) showed a projecting saccular aneurysm below the right renal artery. We placed a stent-graft just below the right renal artery, successfully excluding the abdominal aortic aneurysm (AAA). His C-reactive protein level and white blood cell count remained elevated after stent-grafting. About 5 months later, he was readmitted with recurrent back and lower abdominal pain and CT showed progression of the AAA. Thus, we performed straight grafting using a woven Dacron graft just below the right renal artery. The patient had an uneventful postoperative course. We discuss the controversial issue of treating AAA in patients with Behçet's disease, focusing on the indications and timing of surgery.

Initial impact of drug-eluting stents on coronary artery bypass grafting.

The impact of drug-eluting stents (DES) on the characteristics and operative results of patients referred for coronary artery bypass grafting (CABG) was studied. We reviewed data from isolated CABG patients 24 months before (group A, n = 134) and 24 months after (group B, n = 98) the introduction of DES for clinical use at Teikyo University Hospital in Tokyo. Group B patients were significantly older than those of group A (66 +/- 9 versus 69 +/- 9 years old). The number of diseased vessels was significantly larger in group B (2.5 +/- 0.6 versus 2.7 +/- 0.5) and left main trunk disease decreased in group B (27% versus 17%). Preoperative IABP support was more frequent in group B (9% versus 17%) and beating heart surgery was significantly more frequent in group B (26% versus 59%). The number of grafts was similar in the 2 groups (3.2 +/- 1.4 versus 3.0 +/- 1.1). The operative mortality rates were 0.7% and 4.1% in group A and B, respectively. Incomplete revascularization followed by postoperative percutaneous coronary intervention (PCI) was performed in 11% and 12%, respectively, and all the patients survived surgery. The operative mortality rates for arrested heart and beating heart surgery were 2% and 2%, respectively. In conclusion, after the introduction of DES, more clinically ill patients were referred to CABG. Combination therapy consisting of CABG and PCI (Hybrid) may be a treatment of choice in critical patients.

Beraprost sodium-induced hypotension in two patients after cardiac surgery.

Two episodes of hypotension caused by oral beraprost sodium administration following cardiac surgery are described. The first case was a 67-year-old female who underwent concomitant surgery for mitral valve replacement, tricuspid annuloplasty, and a radiofrequency maze procedure for atrial fibrillation. The second case was a 45-year-old female who underwent 4-vessel coronary artery bypass grafting associated with endarterectomy in the right coronary artery. Beraprost sodium was administered for the treatment of residual pulmonary hypertension in the first case, and was initiated as an antiplatelet agent following coronary endarterectomy in the second case. Hypotension occurred at approximately one hour after beraprost sodium administration in both cases. Careful observation to prevent this adverse effect is critical after the administration of beraprost sodium, especially in patients who have undergone cardiac surgery.