[Sudden Chest Pain due to Early Bioprosthetic Valve Dysfunction:Report of a Case].

We report a case of bioprosthetic valve dysfunction and acute aortic valve regurgitation. The case was a 75-year-old female who had sudden onset chest pain. ST-segment depression in several leads on electrocardiogram( ECG) suggested acute coronary syndrome. Coronary angiography showed no significant stenosis in coronary arteries. Transesophageal echocardiography revealed severe aortic regurgitation, suggesting that angina was caused by myocardial ischemia associated with acute aortic regurgitation. She was diagnosed as having bioprosthetic valve dysfunction, and underwent redo aortic valve replacement. One leaflet of the bioprosthetic valve was torn along the stent post and caused bioprosthetic valve dysfunction. Failed bioprosthetic valve was removed and replaced by a mechanical valve.

[Traumatic Ascending Aortic Injury with Delayed Cardiac Tamponade due to Sternal Fracture].

The case was a 63-year-old male. He had a history of surgery for funnel chest at the age of 23. He overdrank and hit the anterior chest about two weeks before. He complained of persistent chest pain and palpitation, and was admitted because of atrial fibrillation and moderate pericardial fluid. Computed tomography (CT) showed a new sternal fracture, but dislocation and instability was mild. A few days later, sinus rhythm was restored and his heart failure improved. Unfortunately, on the 7th day, he suddenly suffered cardiopulmonary arrest. Ultrasonography revealed cardiac tamponade, and pericardiocentesis yielded 400 ml of bloody pericardial fluid collection. CT demonstrated clot mainly in the anterior pericardium, and emergent operation was performed. Bleeding from the anterior wall of the ascending aorta was repaired by placing one stitch. Postoperatively the patient remained unconscious, and CT of the brain showed hypoxic encephalopathy. After prolonged ventilator management, he was transferred to a rehabilitation hospital. In retrospect, the ascending aorta was close to the sternum in this patient, and sternal fracture might have caused injury of the ascending aorta.

Efficacy of Plasma free Hemoglobin for detecting centrifugal pump thrombosis.

INTRODUCTION: Lactate dehydrogenase (LDH) is widely used as an indicator of pump thrombosis in a centrifugal pump. However, due to the low specificity of LDH, pump thrombosis is difficult to detect in the clinical environment. We measured plasma free hemoglobin (pfHb) with the portable device in ICU. The goal of this investigation is to evaluate its diagnostic ability for pump thrombosis. METHODS: We enrolled 31 consecutive patients who needed Extracorporeal Membrane Oxygenation (ECMO) therapy and pfHb was determined with HemoCue® plasma/Low Hb photometer. Pump thrombosis was analyzed macroscopically at the timing of pump explantation or exchange. Also, we divided the pump thrombosis into a grading scale by the place of thrombosis. RESULTS: The median of peak pfHb was significantly lower in the none thrombus group (0.03 g/dL) than that of in the thrombus group (0.05g/dL) (p = 0.01). In our grading criteria, pfHb was significantly higher when the thrombus is existing near the shaft (p = 0.015). Contrary, no significant difference was found for LDH.The ROC analysis of pfHb revealed an AUC of 0.77 for detecting pump thrombosis with the best statistical cutoff value at 0.05 g/dL (specificity, 78%; sensitivity, 77%). Also, ROC analysis of LDH was performed (AUC, 0.44; cutoff value, 1200 IU/L; specificity, 59%; sensitivity, 54%) and compared with pfHb. AUC was significantly higher in pfHb (p = 0.04). CONCLUSION: Our results showed the efficacy of pfHb for detecting centrifugal pump thrombosis.

[Video Assisted Left Ventricular Pseudoaneurysm Repair].

An 80-year-old male was admitted to our hospital because of subacute myocardial infarction with moderate mitral regurgitation. Though he recovered well and went home within 2 weeks, the transthoracic echocardiography revealed rapid growing aneurysmal changes at the left ventricular posterior wall. We made diagnose of a pseudoaneurysm by the multi detector-row computed tomography, and planed a surgical treatment. Following the cardiac arrest, an endoscope was inserted into the left ventricle, we inspected the relation between the mitral valve and papillary muscles to detect proper suture lines and to avoid the mitral regurgitation. The defect of the left ventricular wall was repaired with 2-layer bovine pericardial patches reinforced with fibrin glue. His postoperative course was uneventful, and he was discharged from hospital on 12th postoperative day. We consider that inspections of intra-ventricle apparatus with the endoscope are useful to prevent the mitral valve insufficiency and keep the optimal left ventricle shape.

[Aortoesophageal Fistula due to Aortic Aneurysm;Report of a Case].

A 77-year-old woman presented with general fatigue, was found to have anemia, and was referred to our hospital. Upper gastrointestinal endoscopy revealed a submucosal elevated lesion with a bleeding site and debris at the middle thoracic esophagus. Enhanced computed tomography demonstrated a thoracic aortic aneurysm compressing the esophagus. She was diagnosed with an aorto-esophageal fistula due to the thoracic aortic aneurysm. Graft replacement was performed under partial extracorporeal circulation. Because the perforation of the esophagus was small, omental flap transposition was performed without esophagectomy. Her post-operative course was uneventful, and she has been doing well without any infective episodes over 3 years after surgery.

[Corrected Transposition of the Great Arteries, Ventricular Septal Defect, Tricuspid Regurgitation and Pulmonary Hypertension Operated at Middle Age: Report of a Case].

A 45-year-old male with corrected transposition of great arteries and the ventricular septal defect (VSD) was considered to have no indication for the total repair because of severe pulmonary hypertension in his young age. He was suffered from heart failure with absence at the age of 44. Detail examinations revealed the severe tricuspid valve regurgitation with VSD. We reevaluated him for the operative indication by the aspect of pulmonary hypertension. His pulmonary vascular resistance decreased with the administration of 100% oxygen, and no pulmonary vascular obstructions were detected in the lung specimen. As a result, he underwent VSD patch closure and tricuspid valve replacement. His postoperative course was uneventful and he was discharged from our hospital at day 16 postoperatively. Our data suggested that reevaluation including lung biopsy should be important to determine operative indication for adult congenital heart disease.

[A case with Stanford type A acute aortic dissection that presented with consciousness disturbance and hemiparesis].

The patient was a 63-year-old female who had a past history of hypertension. She suddenly complained of agonizing pain and became comatose soon thereafter. Upon admission, she was in a state of shock, with upper airway obstruction and a coma. The pupils were dilated on both sides. The laboratory data showed that D-dimer was >80µg/mL. Brain CT scan and diffusion weighted MRI of the brain showed no abnormality. On brain 2D-CT angiography, the visualization of the right internal carotid artery and the right vertebral artery was poor. She eventually was able to nod her head in response to verbal commands, but her left extremities were completely hemiplegic. Cerebral angiography showed occlusion of the right vertebral artery at the branching point from the brachiocephalic artery, and was visualized in a retrograde fashion through the left vertebral artery. The brachiocephalic artery was severely stenotic in aortography. During angiography, she became able to speak and complained of back pain. Chest CT just after angiography showed a dissection in the aortic arch. Therefore, she was directed to the cardiovascular surgeon for immediate consultation. During the operation, the aortic dissection was revealed to be Stanford type A. Laceration of the intima was found in the ascending aorta and cardiac tamponade was also found. Total arch replacement was performed. The pathological examination showed that the arterial dissection occurred in the layer of elastic fiber, and the minimum arterial thickness of the medial layer was 0.2mm. The patient improved after the operation and her neurological deficits disappeared completely 13 days after operation. Brain and spinal MRI 15 days after the operation showed no abnormality.

[Left atrial posterior wall flap method for II a type of the isolated total anomalous pulmonary venous drainage].

We address the left atrial posterior wall flap (LAPF) method for the isolated total anomalous pulmonary venous drainage( TAPVD) II a. The postoperative pulmonary venous obstruction( PVO) is a serious complication and is not rare after repair of the isolated TAPVD II a by the conventional surgical techniques. The LAPF method contains superiorities to prevent PVO to the conventional surgical techniques by wider left atrium(LA) - pulmonary vein(PV) communication, less risk of turbulence and no need of a prosthetic patch or an autologous pericardial patch. Furthermore, from a hemodynamic point of view, it makes LA-PV communication a functional preloading chamber which leads the postoperative hemodynamics stable. So, we think that the LAPF method is able to be a standard operative technique for the isolated TAPVD II a.

[Acute type a aortic dissection operated in childhood; report of a case].

A 12-year-old boy without any previous history and risk factors of cardiovascular disease presented to the emergency room with persisting general fatigue, bilateral shoulder pain and facial pallor. He was diagnosed as acute type A aortic dissection with cardiac tamponade by ultrasonic cardiogram (UCG) and computed tomography (CT) imaging, and the emergency surgery was indicated. He underwent hemiarch replacement because his aorta diameter was quite small but grafting as a large vascular prosthesis as possible was necessary in consideration of the growth. His postoperative course was uneventful and good, and he was discharged from our hospital in day 21 postoperatively. Acute aortic dissection in childhood is very rare but life-threatening. We should consider the particularity of children and make early diagnosis and treatment appropriately.

Warfarin-induced toxic epidermal necrolysis after mitral valve replacement.

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare diseases that cause acute destruction of the epithelium of the skin and mucous membranes, almost always attributable to drugs. However, warfarin-induced Stevens-Johnson syndrome and toxic epidermal necrolysis is extremely rare. We report the case of 71-year-old woman who died due to destructive erosion all over her skin and mucous membranes. She had received a mitral valve prosthesis, and warfarin was prescribed for antithrombotic therapy. A lymphocyte transformation test for drug hypersensitivity and the clinical history confirmed this phenomenon as warfarin-induced toxic epidermal necrolysis.

Giant biatrial myxoma with two different gross findings.

We experienced a giant biatrial myxoma concomitant with hepatocellular carcinoma. Most of myxomas originate from the left atrium, and biatrial myxomas are extremely rare. Excision of the giant cardiac tumor was performed to avoid risks of life-threatening complications. The resected mass was grossly composed of two parts with the border of interatrial septum and with the shape of peanut shell. Although microscopic examinations revealed enlarged vessels, hemorrhages and hemosiderosis in the left part and high cellularity with chronic inflammation in the right part, spindle-shaped cells in a loose myxoid stroma were observed in both parts of the tumor, consistent with the diagnosis of myxoma. His second operation for hepatic cancer was successfully performed following 1 month after the first operation. Surgical treatment should be considered for giant atrium tumor which has risk of life-threatening complications even if patients have another cancer.

Pseudoaneurysm from the mitral-aortic intervalvular fibrosa following endocarditis.

A rare case of a pseudoaneurysm from the mitral-aortic intervalvular fibrosa following bacterial endocarditis in a 17-year-old male is presented. Destructive infection secondarily involved the mitral-aortic intervalvular fibrosa. Perforation of this portion resulted in the formation of the pseudoaneurysm situated at the base of the left ventricle between the aorta and the left atrium. With echocardiography, computed topography, angiography, and magnetic resonance imaging (MRI), a pseudoaneurysm was diagnosed. MRI especially revealed detailed information and the extension of pseudoaneurysm. Our patient underwent resection of the pseudoaneurysm, reconstruction of left ventricular outflow with glutaraldehyde-preserved bovine pericardium, and replacement of the aortic valve. His postoperative course was uneventful. No recurrence of endocarditis was detected in the following year.

[Chronic traumatic aneurysm of the thoracic aorta; report of a case].

We report a rare case of chronic traumatic aneurysm of the thoracic aorta. A 23-year-old man flew down from the fifth floor of his apartment for an attempted suicide. He suffered right subdural hematoma, bilateral hemothorax, lung contusions, and many other traumas. He was paralyzed by the fracture and dislocation of the first lumbar vertebra. Posterior fixation of lumbar vertebra and the segmental resection of the jejum were performed on the first and third day, respectively. He recovered well; however, he complained his nocturnal dyspnea on the forty-fifth day. Detailed examinations showed that bilateral bronchi were compressed by the aneurysm of thoracic aorta. Elective operation was performed on the sixty third day. Psudoaneurysm, 5 cm in diameter, was disclosed in the aortic isthmus. Graft replacement was undergone with the cardiopulmonary bypass. His postoperative course was uneventful, and he was transferred for the rehabilitation of his paralysis on the eigty-eighth day.

Acute occlusion of left coronary ostium associated with congenital quadricuspid aortic valve.

A 10-year-old girl suffered from chest discomfort during exercise. She experienced an acute myocardial infarction accompanied by an obstruction in an orifice to the left coronary artery. An emergency operation revealed that the aortic valve was quadricuspid, and a left-sided small cusp had adhered to the aortic wall resulting in an unusual sac with a tiny slit. Resection of the sac disclosed the ostium to left coronary artery. Blood toward the left coronary artery passed through the tiny slit. The mechanisms of obstruction in the coronary artery were uncertain. She recovered well after the aortic valve replacement with resection of the aortic cusps.