[Dysphagia and Aspiration Pneumonia Caused by Kommerell's Diverticulum and the Vascular Ring Associated with Right-sided Aortic Arch:Report of a Case].

We report a case of an 80-year-old man complaining of dysphagia followed by aspiration pneumonia. Computed tomography of the chest revealed Kommerell's diverticulum associated with the right-sided aortic arch and the vascular ring which was formed by the aortic arch, the left subclavian artery, the ductus arteriosus, and the pulmonary artery around the esophagus and the trachea. Enlargement of the diverticulum was considered to be the cause of dysphagia. The surgery was performed at 20 ℃ under deep hypothermic circulatory arrest. We performed resection of the Kommerell's diverticulum, reconstruction of the left subclavian artery, and transection of the ductus arteriosus to relieve the compression by the esophagus and the trachea. The postoperative course was uneventful and dysphagia disappeared.

Delayed traumatic aortic valve perforation after blunt chest trauma.

BACKGROUND: Aortic valve perforation is a rare complication of blunt chest trauma. We report a case of delayed aortic insufficiency presenting several months after trauma. CASE PRESENTATION: A 17-year-old male presented to the emergency department with traumatic brain injuries and blunt chest trauma, but no evidence of cardiac injuries. Three months later, he developed acute heart failure due to severe aortic valve regurgitation with left ventricular dysfunction. A sizable tear in the right coronary cusp caused aortic insufficiency. He was treated successfully by surgical replacement with an aortic bioprosthesis. CONCLUSION: We reported a successful surgical case of valve replacement for delayed aortic valve perforation. Delayed valve perforation should be kept in mind after blunt chest trauma.

Flexible Total Ring Annuloplasty With Continuous Wrapping Suture Considering the Anatomy and Histology of the Tricuspid Valve.

OBJECTIVE: About half of tricuspid valves (TVs) have 2 posterior leaflets, and the fibrous tissue of the tricuspid annulus is poor. Considering the anatomy and histology of the TV, we devised a secure ring annuloplasty technique. We herein report the outcomes of our continuous wrapping suture annuloplasty technique using a flexible total ring. METHODS: We used a Tailor™ ring (Abbott, Chicago, IL, USA) as a full ring. The mark on the left side of the ring was fixed to the anteroseptal commissure, and the midpoint of the ring's markers was fixed at the center of the septal leaflet annulus. Using a continuous suture, all stitches were passed around the annuloplasty ring without penetration. One suture from the anteroseptal commissure ran toward the left side and another from the midpoint of the septal leaflet annulus ran toward the right, leading to annuloplasty without TV deformation. RESULTS: Eighty patients underwent TV repair with this technique. The tricuspid regurgitation (TR) score in all patients improved from 1.9 ± 0.7 to 0.8 ± 0.4 (P < 0.001) at 3 years postoperatively. The TR score of TVs with 2 posterior leaflets also improved from 1.9 ± 0.7 to 0.6 ± 0.4 after the operation and was unchanged during follow-up. The median follow-up period was 1.3 (0.5 to 2.0) years, and no patients required TV reoperation. The 3-year survival rate was 93%, and the 3-year rate of freedom from pacemaker implantation was 95%. CONCLUSIONS: The continuous wrapping suture technique using a flexible total ring is a useful procedure without TV deformation even when 2 posterior leaflets are present.

Midterm Results of Mitral Valve Repair Using Loop Technique With Simple Height Reduction of the Large Posterior Leaflet.

OBJECTIVE: Systolic anterior motion (SAM) is one of the most serious problems in mitral valve repair. Height reduction is a key procedure to solve SAM, and there are limited data on the surgical results of height reduction procedure. This study is to assess the effectiveness and midterm results of simple height reduction procedure for SAM in patients with severe mitral regurgitation (MR). METHODS: From 2008 to 2022, 50 patients underwent loop technique with an additional simple height reduction procedure for prevention of SAM. We examined the midterm results of patients with simple height reduction regarding recurrent MR and reoperation. The follow-up period ranged from 171 to 3,816 days (median, 883 days). RESULTS: There were 338 patients (87%) who underwent loop technique without height reduction and 50 patients (13%) who underwent loop technique with height reduction. After the height reduction procedure, SAM was prevented in 44 patients, and 6 patients needed volume loading to suppress SAM. Freedom from recurrence of moderate to severe or severe MR at 1, 3, and 5 years was 98%, 88%, and 88% in the height reduction group versus 98%, 96%, and 94% in the group with loop technique alone (P = 0.074). Receiver operating characteristic curves showed that a systolic dimension of 26 mm had a sensitivity of 75% and a specificity of 83% for predicting SAM after height reduction. CONCLUSIONS: Loop technique with simple height reduction was a simple, secure, and effective procedure to prevent SAM and recurrent significant MR in the midterm periods.

Vascular access site complications after transfemoral transcatheter aortic valve implantation: a comparison of open and percutaneous puncture approaches.

Background: In transfemoral transcatheter aortic valve implantation (TF-TAVI), which approach has lower vascular access site complications between the open puncture (OP) and percutaneous puncture (PP) approaches is still controversial. Moreover, few studies have analyzed risk factors for vascular access site complications in TF-TAVI. This study aimed to compare vascular access site complications between the OP and PP approaches in patients undergoing TF-TAVI and access risk factors for vascular access site complications. Methods: Three hundred fifty-one patients who underwent TF-TAVI via the PP (n=251) and OP (n=100) were retrospectively examined. Results: Incidence of vascular access site complications was 7.0% in the OP group and 8.4% in the PP group (P=0.828). Two deaths from vascular access site complications occurred in the PP group. After performing inverse probability weighting (IPW), regression analysis showed that PP was associated with a significantly higher odds of vascular access site complications [odds ratio =2.033; 95% confidence interval (CI): 1.397-2.958; P<0.001]. Common femoral artery (CFA) depth (hazard ratio =1.04; 95% CI: 1.000-1.070; P=0.045) and sheath/CFA diameter ratio (hazard ratio =971; 95% CI: 22.6-41,700; P<0.001) were independent complication risk factors. In patients with CFA depth ≥35 mm, the incidence of vascular access site complications was higher with PP than OP. Sheath/CFA diameter ratio ≥0.9 was associated with increased risk of vascular injury with both approaches. Conclusions: The incidence of vascular access site complications in patients undergoing TF-TAVI was significantly lower with OP than PP after IPW. OP may be preferable when CFA depth is ≥35 mm. When the sheath/CFA diameter ratio is ≥0.9, approaches other than the TF approach should be considered.

Three-dimensional transesophageal echocardiographic morphological evaluation of the tricuspid valve.

OBJECTIVES: The morphology of the tricuspid valve (TV), particularly valves with two posterior leaflets, is attracting attention. The present study was performed to investigate the usefulness of three-dimensional transoesophageal echocardiographic data for morphological evaluation of the TV . METHODS: Sixty patients underwent morphological evaluation of the TV by preoperative transoesophageal echocardiography followed by TV repair with median sternotomy, and each leaflet was measured intraoperatively. We analysed the TV morphology in 51 patients whose preoperative echocardiographic findings were consistent with intraoperative findings. RESULTS: The mid-systolic echo data, which included the annulus diameter of each leaflet, were correlated with the intraoperative evaluation findings compared with those in the mid-diastole. The annulus and area of the posterior leaflet were larger in patients with two than one posterior leaflet valve (42.4 ± 13.5 vs 30.7 ± 9.1 mm, P < 0.001 and 327 ± 185 vs 208 ± 77 mm2, P = 0.006, respectively). In the severe tricuspid regurgitation patients, the annulus of the posterior leaflet was larger and the annulus of the anterior leaflet was smaller in patients with two than one posterior leaflet valve [posterior: 48 mm [95% confidence interval (CI), 41-54 mm] vs 36 mm (95% CI, 27-45 mm), respectively; P = 0.043 and anterior: 38 mm (95% CI, 33-42 mm) vs 46 mm (95% CI, 40-52 mm), respectively; P = 0.025]. CONCLUSIONS: Patients who had a TV with two posterior leaflets had a larger annulus and area of the posterior leaflets. Preoperative three-dimensional transoesophageal echocardiography is useful for the morphological evaluation of the TV.