Extended Posterior Leaflet Augmentation for Ischemic Mitral Regurgitation　- Augmented Posterior Leaflet Snuggling up to Anterior Leaflet.

BACKGROUND: The ideal surgical technique for ischemic mitral regurgitation (MR) is controversial. We introduced an extended posterior mitral leaflet (PML) augmentation technique for functional MR with severe tethering, which detached the PML from the annulus almost completely and augmented it with a large 3×6-cm oval pericardial patch. Methods and Results: A total of 17 mitral repairs using the new technique were performed for ischemic MR with no 30-day mortality and 2 hospital deaths. The NYHA class was III in 47% and IV in 13%. The EuroSCORE II was 9.7±4.9. The ring size was 32±1.4 mm. Concomitant coronary bypass was performed in 67% and left ventricular repair in 28%. The mechanism of leaflet closure was evaluated using transthoracic echocardiography in 15 survivors. MR decreased to none or trivial with a significant increase in coaptation length (Pre: 4.6±0.8 mm vs. Post: 9.8±2.5 mm; P<0.001). The PML flexibly moved forward and tightly contacted as if "snuggling up" to the anterior leaflet. There were no late deaths, heart failure readmissions or MR recurrences during follow-up (850±181 days). All patients remained in NYHA I or II. CONCLUSIONS: Extended PML augmentation for ischemic MR showed excellent early results with deep leaflet coaptation through a "snuggling up" phenomenon, which would help prevent late MR recurrence.

Successful management of prolonged venovenous extracorporeal membrane oxygenation in an octogenarian.

Venovenous extracorporeal membrane oxygenation is now an established treatment for acute respiratory distress syndrome. However, this treatment remains rare in octogenarians and is associated with poor outcomes. An 81-year-old man with a history of chronic obstructive pulmonary disease and heavy smoking underwent mitral and tricuspid valve repair and the Maze procedure for mitral and tricuspid regurgitation and paroxysmal atrial fibrillation. Although he was extubated the following day, his postoperative course was complicated with pneumonia followed by acute respiratory distress syndrome. He was reintubated on day 7. Ratio of partial pressure of arterial oxygen to fraction of inspired oxygen continuously dropped to less than 100 mmHg, and venovenous extracorporeal membrane oxygenation support was induced on day 18. His lung condition showed slow and steady recovery, and he was successfully weaned from mechanical support on day 44 (total support, 27 days). Bleeding complication from tracheotomy (day 31) due to disseminated intravascular coagulation was successfully managed using recombinant human soluble thrombomodulin. He was ambulatory and discharged to a nursing facility without tracheotomy on day 172. Proper extracorporeal membrane oxygenation management, while challenging to keep the elderly patient away from further complications, saved an 81-year-old patient.

Mid-term results of mitral valve repair with autologous pericardium in pediatric patients.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair to treat mitral regurgitation (MR) in pediatric patients remains challenging because of the complex morphology and fragility of the leaflets. The study aim was to review retrospectively the authors' experience with mitral valve repair using autologous pericardium. METHODS: Between April 2004 and November 2011, nine pediatric patients (six males, three females; mean age 2.4 +/- 4.5 years) underwent mitral valve repair with an autologous fresh (n = 5) or glutaraldehyde-treated pericardium (n = 4) to treat severe MR. The etiology of the MR was acute endocarditis, acute chordal rupture and congenital disease in three, two, and four patients, respectively. Autologous pericardium was used for valvuloplasty, leaflet extension plasty and commissuroplasty in two, five, and two patients, respectively. Artificial chordal replacement was performed in three patients. RESULTS: No operative deaths or postoperative endocarditis occurred. One patient required mitral valve replacement at three days after the initial mitral repair. The most recent echocardiography findings of the remaining patients after a mean of 6.3 years (range: 1.3-9.0 years) showed that the severity of mitral insufficiency, left ventricular diastolic diameter and fractional shortening were 1.8 +/- 0.6 (grades 0-4), 40.4 +/- 8.4 mm (114.2 +/- 15.8% of normal) and 35.0 +/- 5.0%, respectively. CONCLUSION: Mitral valve repair using autologous fresh pericardium is associated with mid-term durability and resistance to infection when used for mitral valve repair of active endocarditis in pediatric patients. Augmentation with autologous pericardium could become an alternative to current surgical options.

Aortic arch augmentation using a pulmonary artery autograft patch and a reversed left subclavian artery flap for an interrupted aortic arch type B complex.

Adequate arch augmentation for interrupted aortic arch repair is quite important to avoid post-operative recoarctation and bronchial compression. We describe here two successful cases of aortic arch reconstruction using autologous materials such as a pulmonary artery patch and a reversed left subclavian artery flap in infants with an interrupted aortic arch type B complex.

A true aneurysm of posterior tibial artery.

True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman who suffered from a distal embolism in the left toes. The surgical intervention involved an aneurysmectomy and the interposition of the posterior tibial artery using the saphenous vein graft. She has been doing well 22 months after the operation.

Rapidly Progressed Distal Arch Aneurysm with Distal Open Stent Graft-Induced New Entry Caused by "Spring-Back" Force.

The J Graft Open Stent Graft (JOSG) is used for the frozen elephant trunk procedure in Japan. We report a 70-year-old male who developed a rapidly progressing distal arch aneurysm caused by a distal stent graft-induced new entry (DSINE) 7 months after the procedure. The JOSG was originally implanted at the curved part of the distal arch. It created its initial DSINE on the greater curve and rapidly "sprang" back in 2 months. Urgent thoracic endovascular aortic repair fixed this serious complication. We should remember such rapid progression of DSINE by JOSG and treat its initial sign earlier.

Risk Factors for Atrial Fibrillation Recurrence After Cox Maze IV Performed Without Pre-exclusion.

BACKGROUND: New guidelines from The Society of Thoracic Surgeons recommend adding surgical ablation as a concomitant procedure for class I indications. We performed the maze procedure for all patients who experienced atrial fibrillation (AF) before cardiac surgery, without surgeon pre-exclusion. METHODS: We retrospectively analyzed 83 patients, aged 71 ± 11 years (22% >80 years), who underwent Cox maze IV for persistent AF between 2014 and 2017. The mean AF duration (AFD) was 6.9 ± 8.6 years and European System for Cardiac Operative Risk Evaluation II was 7.2 ± 6.8. RESULTS: The 30-day mortality was 2.4%. During follow-up (mean, 675 days), the 1-, 2-, and 3-year survival rates were 92%, 86%, and 82%, respectively. No strokes were observed despite a mean CHA2DS2-VASC (Congestive heart failure, Hypertension, Age [≥65 = 1 point, ≥75 = 2 points], Diabetes, and Stroke/transient ischemic attack [2 points], vascular disease, Sex [female = 1 point]) score of 4.1 (expected stroke rate, 4%/y). Twelve patients required a new pacemaker; 56 of 73 survivors (77%) remained AF free. Multivariate logistic regression identified preoperative AFD, f wave size, and mean heart rate per Holter as important risk factors for AF recurrence, with AFD as the most important: 98% of patients with AFD less than 5 years remained AF free. Although the AF-free rate with the AFD of 5 or more years was only 55%, their symptoms improved without heart failure readmission. Concomitant atrial plication was performed more frequently in the group with AFD for 5 or more years, with greater atrial volume reduction and appreciable increases in stroke volume. CONCLUSIONS: The Cox maze IV procedure performed without pre-exclusion showed reasonable survival rates. Although AF recurred in patients with longer AFD, they fared well with substantial increases in stroke volume. Concomitant atrial volume reduction may have contributed to these additional benefits.

Preemptive angioplasty for contralateral leg stenosis following EXCLUDER Iliac Branch Endoprosthesis implantation.

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) device is designed to seal off a common iliac artery (CIA) aneurysm, preserving the internal iliac artery during endovascular aortic repair. We report the case of an 84-year-old man with isolated saccular right CIA aneurysm (35 mm) and a relatively small terminal aorta (24 mm). The IBE device was successfully placed, and intraoperative angiography revealed no leakage or delay. However, postoperative computed tomography revealed marked compression of the contralateral leg by a bridging component. Although his ankle-brachial index was preserved, its acute occlusion was judged highly possible; we decided to perform preemptive angioplasty. The angiography revealed the stenosis only in the left anterior oblique view, and angioplasty was uneventfully performed. The leg was successfully patent at 1-year follow-up. When compression by IBE and bridging component in the terminal aorta is expected, caution should be preserved at intraoperative angiography following the device deployment.

Post-cardiotomy venovenous extracorporeal membrane oxygenation without heparinization.

We present the cases of eight patients (mean age 75 years; EuroSCORE II 17.0 ± 22.0) who underwent post-cardiotomy venovenous extracorporeal membrane oxygenation (ECMO) without heparinization due to serious bleeding. Three liver cirrhosis, two chronic hemodialysis, three redo sternotomy, and two urgent surgery cases were included. Respiratory ECMO Survival Prediction score was - 5.1 ± 4.2 (estimated survival rate: approximately 30%). Mean ECMO duration was 14 days with 9 circuit exchanges. Five patients were weaned from ECMO and three were discharged alive at 90 days (survival 37.5%). There was a case of pump-head thrombosis requiring urgent circuit exchange. All experienced bleeding complications without clinically apparent pulmonary thromboembolism. Disseminated Intravascular Coagulation scores (Pre 1.3 ± 0.8 vs. Post 3.8 ± 1.7; p < 0.05) significantly increased (N = 6). Post-cardiotomy ECMO without heparinization facilitated patient rescue at a reasonable survival rate. However, bleeding complications were still observed. More sophisticated management protocols are warranted.

Long-standing persistent effects of atrial volume reduction combined with pulmonary vein isolation.

Although surgical left atrial (LA) volume reduction combined with mitral valve surgery and/or surgical ablation for atrial fibrillation has been reported to be effective, its long-term outcomes in the absence of mitral procedure are not well established. A 74-year-old man with two previous sternotomies-the first for pericardiectomy due to constrictive pericarditis and the second for mitral valve replacement with mechanical valve and tricuspid annuloplasty-presented with heart failure and thrombus in his giant left atrium (1291 mL), complicated by cerebral infarction. His electrocardiogram showed rate-controlled persistent atrial fibrillation. His mechanical valve was functioning well. A third atrial volume reduction combined with pulmonary vein isolation, without valve surgery, was performed. The postoperative course was uneventful, and the patient has remained asymptomatic with regular junctional rhythm and without any episodes of thromboembolism or re-dilation of LA (approximately 550 mL). His left ventricular filling improved with end-diastolic volume (96 mL vs 140 mL) and forced vital capacity (2.60 L vs 2.89 L) increased. Both remained relatively constant for 6 years. The combination of atrial volume reduction with pulmonary vein isolation prevented thromboembolism, improved left ventricular filling, and continued to improve symptoms associated with heart failure and respiratory condition for 6 years. .

Successful Repair of Regurgitant Pentacuspid Pulmonary Valve Combined With Pulmonary Artery Aneurysm.

Pentacuspid pulmonary valve is an extremely rare congenital anomaly. A 71-year-old woman presented with dyspnea on exertion. The preoperative examination showed a large pulmonary artery aneurysm with severe pulmonary regurgitation. The pentacuspid pulmonary valve was an intraoperative finding with four equivalent leaflets and one hypoplastic leaflet. The valve was successfully repaired by use of a bicuspidization technique combined with annuloplasty, and pulmonary artery reduction was performed. Postoperatively, the patient remained asymptomatic with trivial pulmonary regurgitation 1 year later. To our knowledge, this is the first report of a pentacuspid pulmonary valve repair.

Rigorous patient-prosthesis matching of Perimount Magna aortic bioprosthesis.

BACKGROUND: Severe patient-prosthesis mismatch, defined as effective orifice area index ≤0.65 cm(2) m(-2), has demonstrated poor long-term survival after aortic valve replacement. Reported rates of severe mismatch involving the Perimount Magna aortic bioprosthesis range from 4% to 20% in patients with a small annulus. METHODS: Between June 2008 and August 2011, 251 patients (mean age 70.5 ± 10.2 years; mean body surface area 1.55 ± 0.19 m(2)) underwent aortic valve replacement with a Perimount Magna bioprosthesis, with or without concomitant procedures. We performed our procedure with rigorous patient-prosthesis matching to implant a valve appropriately sized to each patient, and carried out annular enlargement when a 19-mm valve did not fit. The bioprosthetic performance was evaluated by transthoracic echocardiography predischarge and at 1 and 2 years after surgery. RESULTS: Overall hospital mortality was 1.6%. Only 5 (2.0%) patients required annular enlargement. The mean follow-up period was 19.1 ± 10.7 months with a 98.4% completion rate. Predischarge data showed a mean effective orifice area index of 1.21 ± 0.20 cm(2) m(-2). Moderate mismatch, defined as effective orifice area index ≤0.85 cm(2) m(-2), developed in 4 (1.6%) patients. None developed severe mismatch. Data at 1 and 2 years showed only two cases of moderate mismatch; neither was severe. CONCLUSIONS: Rigorous patient-prosthesis matching maximized the performance of the Perimount Magna, and no severe mismatch resulted in this Japanese population of aortic valve replacement patients.

Mitral commissural repair with autologous fresh pericardium in an infant.

We describe the successful mitral valve repair with autologous fresh pericardium in a 5-month-old infant with acute progressive mitral regurgitation. The intraoperative findings consisted of fragile mitral valve leaflets with multiple chordal rupture of both the anterior and posterior leaflets. The disrupted anterolateral commissure was reconstructed using autologous fresh pericardium, a technique not previously reported in an infant of this size. Follow-up echocardiography for up to 7 years showed only trivial mitral regurgitation and no mitral stenosis.

Successful bicuspid aortic valve repair using external aortic annuloplasty.

A 33-year-old man presented with severe aortic insufficiency due to a prolapsed bicuspid aortic valve. The ventriculoaortic junction was dilated to 29 mm without root dilatation, and external ring annuloplasty was performed using a Gelweave (Terumo, Tokyo, Japan) graft to reduce the size to 22 mm. The leaflets were repaired by dividing and suturing a raphe between the right and left cusps. This combination provided adequate coaptation depth (8 mm) and showed excellent results, with trivial aortic insufficiency. This approach is suitable for repair of a bicuspid aortic valve with a dilated ventriculoaortic junction without root dilatation.

Landiolol for junctional ectopic tachycardia refractory to amiodarone after pediatric cardiac surgery.

Postoperative junctional ectopic tachycardia (JET) in children undergoing cardiac surgery is a serious arrhythmia that is associated with considerable morbidity and mortality. We present here a case of successful landiolol therapy for postoperative JET in a 3-month-old infant who underwent ventricular septal defect closure and right pulmonary artery plasty. His left ventricular function was poor postoperatively. The JET was refractory to amiodarone and caused severe hypotension, which was required cardiac massage. Continuous intravenous infusion of low-dose landiolol reduced the persistent JET rate immediately, and restored to sinus rhythm with stable hemodynamics.

Primary sutureless repair for simple total anomalous pulmonary venous connection with a risk of postoperative pulmonary venous stenosis.

Late mortality following surgical repair of total anomalous pulmonary venous connection (TAPVC) is often associated with pulmonary venous stenosis. We describe here two successful cases of primary sutureless repair for simple TAPVC in patients who had a potential risk of postoperative pulmonary venous stenosis. A 10-day-old neonate with mixed-type TAPVC and a 30-day-old infant with supracardiac TAPVC underwent primary sutureless repair with our modification. In the early follow-up, both patients are now doing well and have no signs of pulmonary venous stenosis. The sutureless repair can be applied as a primary surgical option to prevent postoperative pulmonary venous stenosis in selective patients with simple TAPVC.

Simultaneous complex single ventricle palliation and tracheoplasty for heterotaxy syndrome.

Although isomerism of the bronchial tree is an integral part of hetrotaxy syndrome, the association of congenital tracheal stenosis is rare in this group of disorders, and it has not yet been thoroughly described in the literature. This condition is potentially life-threatening and precludes single ventricle palliation. This report presents the case of a 5-month old infant with symptomatic congenital tracheal stenosis, functionally univentricular heart and extracardiac total anomalous pulmonary venous connection (TAPVC). The condition was successfully treated with bidirectional Glenn anastomosis, central pulmonary artery plasty, repair of TAPVC and slide tracheoplasty.

Aortic root reimplantation for isolated sinus of valsalva aneurysm in the patient with Marfan's syndrome.

We describe an isolated extracardiac unruptured acquired aneurysm in the right coronary sinus of Valsalva, which was seen in a 55-year-old woman with Marfan's syndrome. The patient underwent aortic root replacement using a reimplantation technique. Pathologic examination revealed absence of the medial elastic fiber of the aortic wall of the normal sinus of Valsalva. This result supports the preference of entire root replacement instead of patch repair of the affected sinus for the isolated aneurysm in 1 sinus of Valsalva in a patient with Marfan's syndrome.