[Congenital Unicuspid Aortic Valve Diagnosed by Intraoperative Findings].

A unicuspid aortic valve is an extremely rare congenital aortic valvular abnormality. We herein present 2 cases of unicuspid aortic valve diagnosed based on intraoperative findings. In case 1, a 75-year-old man was admitted to our hospital because of severe aortic regurgitation. We performed aortic valve replacement using a bioprosthetic valve, and a unicuspid aortic valve was definitively diagnosed according to the intraoperative findings. In case 2, a 54-year-old man developed dyspnea due to severe aortic stenosis. Aortic valve replacement using mechanical valve was performed, and we were able to diagnose unicuspid aortic valve intraoperatively. Achieving a preoperative definitive diagnosis of congenital unicuspid aortic valve by transthoracic echocardiography is reportedly difficult;however, transesophageal echocardiography may be effective for preoperative definitive diagnosis.

A Subcutaneous Mass as a Sign of Thoracic Aortic Pseudoaneurysm.

A 39-year-old man on hemodialysis who received total aortic arch repair for dissection of Kommerrel diverticulum 2 months prior, visited an outpatient clinic. He presented with a sudden subcutaneous mass on the anterior chest wall 1 week earlier, that was painless, nonpulsatile, and with a normal skin color. Enhanced computed tomography revealed that the pseudoaneurysm originated from the proximal suture line. At surgery, an aortic intima was observed to be lacking at the native posterior aortic wall located at the proximal suture line with a 10-mm tear. A new graft was implanted after a new proximal suture line was reconstructed.

[Perioperative Management of Acute Type-A Aortic Dissection in a 97-year-old Woman].

A 97-year-old woman with severe back pain was transferred to our hospital. She was able to perform activities of daily living independently and had no neu- rological deficit or dementia before her admission. Con- trast-enhanced computed tomography revealed a rup- ture in the descending aorta and thrombosed type A aortic dissection. We carefully explained the need for and the risks associated with surgery to the patient and her family. After an informed consent had been obtained, she was taken to the operating room for an emergency surgery. Anesthetic management was uneventful. Trans- esophageal echocardiography was useful to evaluate her cardiac function and aortic dissection. We per- formed replacement of the total aortic arch and descending aorta successfully. On the 55th postopera- tive day, she was transferred to another hospital to undergo further physical therapy. The total hospital- ization cost was nearly 9.8 million yen. The medical cost was high in our case. In cases of nonagenarians who require an emergency cardiac surgery, we should consider the patients' age, preoperative activities of daily living, and postoperative quality of life when making decisions on surgery. The patient in our case needed to be carefully treated for airway and swallow- ing management in the early perioperative period.

[Dehiscence of the Pericardial Patch, after Surgical Treatment of Active Infective Aortic Valve Endocarditis with Reconstruction of the Aortic Annulus Using a Glutaraldehyde-treated Autologous Pericardium].

A 50-year-old man was admitted with fever and chill sensation 6 months ago. Transthoracic echocardiography (TTE) showed left and right coronary cusp prolapses and a thickened tissue of the aortic curtain. Congestive heart failure due to active infective aortic valve endocarditis was diagnosed, and he underwent aortic valve replacement. The aortic annulus was reconstructed using a glutaraldehydetreated autologous pericardium. Six months after surgery, TTE showed severe aortic regurgitation and saccular change in the aortic annulus. Transesophageal echocargiography showed some echo free space from left to noncoronary cusp and abnormal movement of the prosthetic valve annulus. Intraoperative examination showed dehiscence of the pericardial patch from the aortic wall, but no finding of infection. Aortic valve rereplacement was performed with reconstruction of the aortic annulus using a bovine pericardium. To prevent the dehiscence of the pericardial patch from the aortic wall, sutures fixing the prosthetic valve were passed from outside of the aortic wall.

[Successful treatment of Candida albicans mediastinitis after open-heart surgery using vacuum-assisted closure device].

An 82-year-old man suffered from Candida albicans mediastinitis following emergency aortic valve replacement. After repeated debridement of the anterior portion of the mediastinum, we applied a vacuum assisted closure device with UrgoTul Absorb placed on the right ventricle. Despite relatively short-term application of this device, mediastinitis was cured in combination with transposition of the great omentum.

Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair.

BACKGROUND: Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it's not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually. CASE PRESENTATION: We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms. CONCLUSION: In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.

Aortic Annular Enlargement with Modified Y-Incision Technique Devised from Preoperative Three-Dimensional Computed Tomography.

The Y-incision technique introduced by Dr. Bo Yang in 2021 is a very innovative technique that can enlarge the aortic annulus by two or more sizes without violating the left atrium or mitral valve. However, we encountered a case in which the left coronary artery ostium was located close to the left-non commissure. Therefore, we considered it would be dangerous to expand the incision to the left coronary annulus. We therefore devised a new technique that enlarges only the noncoronary annulus in an "L" fashion instead of a "Y" fashion. In performing this surgery, preoperative three-dimensional images were useful for understanding the anatomy when planning the aortic annular enlargement procedure. The L-incision technique can be a useful alternative method of aortic annulus enlargement.

Enhanced expression of neopterin in valve tissue of bicuspid aortic stenosis.

Background: Aortic valve stenosis (AS) occurs in bicuspid aortic valve (BAV) patients at a relatively young age compared to tricuspid aortic valve (TAV) patients. However, the underlying cause of this phenomenon remains unknown. Neopterin, which is a by-product of the guanosine triphosphate (GTP) pathway, enhances the oxidative potential of reactive oxygen species. To clarify the role of neopterin in the aortic valve, we immunohistochemically studied the presence of neopterin in aortic valve specimens from patients with AS harboring either TAV or BAV. Methods: Frozen aortic valve samples were surgically obtained from 68 patients with severe AS with TAV (n=34) and BAV (n=34). Normal aortic valves were obtained from cadavers who died of non-cardiovascular causes as controls (n=9). Samples were immunohistochemically stained with antibodies against smooth muscle cells, macrophages, T lymphocytes, neopterin, and 4-hydroxy-2-nonenal (4-HNE). Results: Quantitative analysis showed that the percentage of macrophages, 4-HNE- and neopterin-positive macrophage score, and the number of T lymphocytes were significantly higher in BAV patients than in TAV patients (macrophages, P=0.013; T lymphocytes, P=0.011; neopterin, P<0.001; 4-HNE, P=0.008). Double immunostaining for neopterin and macrophages demonstrated that most neopterin-positive cells were macrophages in BAV patients. Conclusions: Neopterin accumulation in macrophages may increase oxidative stress and contribute to the early onset of AS in BAV.

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.

Mitral valve repair with patch augmentation for atrial functional mitral regurgitation complicated with giant left atrium.

OBJECTIVE: We aimed to assess the results of posterior leaflet augmentation with an autologous pericardial patch in atrial functional mitral regurgitation. METHODS: Data of 16 patients with atrial functional mitral regurgitation who underwent posterior leaflet patch augmentation for mitral valve repair were retrospectively analyzed. This procedure was applied to a short posterior leaflet with a height of < 10 mm in P2. The median age was 72.5 [67.8-78.3] years. Preoperative New York Heart Association functional class was II in 7 (43.8%) and III or IV in 9 (56.2%) patients. Mitral regurgitation was moderate in 2 (12.5%) and severe in 14 (87.5%) patients. RESULTS: Operative mortality occurred in 1 (6.2%) patient due to cerebral infarction. One patient required valve replacement because of patch perforation early after operation. Mitral regurgitation was reduced to less than mild in 15 (93.8%) patients and less than trivial in 11 (68.8%) patients (P < 0.01) postoperatively. As for mid-term results, New York Heart Association functional class improved to I or II in 12 (75%) patients (P < 0.01). Two cases of thrombotic complication were observed. Remote recurrent regurgitation occurred in one case due to small patch size. The 3-year free rate of valve-related morbidity and regurgitation recurrence was 65.6% and 87.1%, respectively. The 5-year survival rate was 93.8%. CONCLUSIONS: Pericardial patch augmentation in atrial functional mitral regurgitation leads to good survival and mitral regurgitation recurrence-free rates. Steady anticoagulation and the use of larger patches would be necessary to reduce thrombotic complications and recurrent MR.

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.

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.

Early outcomes of the Frozenix J-graft with exclusion of the non-stent part at a single center.

Background: The frozen elephant trunk technique is useful in aortic arch repair; however, some adverse events are associated with the Frozenix J-graft. We designed a technique to prevent these adverse events and achieve easy anastomosis (Total Exclusion of the Non-Stent part of Frozenix using an Everting anastomosis [TENSE]), and we assessed the outcomes of this technique in the present study. Methods: From April 2017 to May 2021, 44 patients with aortic arch disease underwent TENSE, in which the proximal stump of the stent part of Frozenix was matched to the distal anastomosis end between the left common carotid and left subclavian arteries. Results: The median age of the patients (35 men, 9 women) was 76.5 years. The predicted mortality and morbidity rates were 10.0% and 40.2%, respectively, according to the JapanSCORE II. Two patients (4.5%) died of aneurysm rupture and interstitial pneumonia, respectively, during hospitalization. Four patients (9.1%) who developed postoperative cerebral infarction had a previous cerebral infarction (P=0.010). No patients developed spinal cord complications or Frozenix kinking. Follow-up computed tomography showed no endoleaks or aneurysmal dilatation, although one patient had possible distal stent graft-induced new entry. Conclusions: Our strategy provided good early outcomes without spinal cord complications or Frozenix kinking in patients with aortic arch disease. Continuous follow-up is needed to avoid missing distal changes.

Morphological diversity of the tricuspid posterior leaflet affects surgical complexity for control of tricuspid regurgitation.

OBJECTIVE: We investigated the effect of morphological diversity of the tricuspid valve with multiple posterior leaflets on the technical outcomes of tricuspid valve repair. METHODS: From April 2016 to November 2020, 141 patients were diagnosed with secondary tricuspid regurgitation associated with left heart disease and underwent tricuspid valve repair. We retrospectively analyzed the clinical and echocardiographic data of patients who underwent both preoperative and postoperative transthoracic echocardiography. We divided the patients into two groups according to the surgical technique used to treat tricuspid regurgitation: ring annuloplasty alone (Group 1, n = 109) or additional approximation of leaflet edges (edge-to-edge repair) with ring annuloplasty (Group 2, n = 32). We measured the morphological diversity of the tricuspid valve during the operation in all patients. RESULTS: The preoperative tricuspid regurgitation score was higher in Group 2 than in Group 1 (2.1 ± 0.78 vs. 1.6 ± 0.7, respectively; p = 0.0046), and Group 2 contained more patients with two posterior leaflets than Group 1 [20 (63%) vs. 36 (33%), respectively; p = 0.003]. The univariate and multivariate logistic regression analyses showed that the presence of two posterior leaflets was an independent risk factor for additional procedures during tricuspid valve repair (odds ratio, 2.6; 95% confidence interval, 1.1-6.1; p = 0.033). CONCLUSIONS: Additional procedures to reduce tricuspid regurgitation were required more frequently in patients with two posterior leaflets of the tricuspid valve. The morphological diversity of two posterior leaflets is a potential risk factor for a more complicated tricuspid repair.

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.

A case of SAPIEN XT valve fallen into left ventricle during valve-in-valve transcatheter aortic valve implantation.

Late transcatheter heart valve embolization is a rare but life-threatening complication of transcatheter aortic valve implantation. Surgical intervention is performed for most cases, but some cases were treated by valve-in-valve transcatheter aortic valve implantation. We describe a patient in whom a 29-mm Edwards SAPIEN XT valve migrated into the left ventricular outflow tract 41 days after the initial implantation. We tried to perform valve-in-valve transcatheter aortic valve implantation using a transfemoral approach. As soon as the second transcatheter heart valve touched the first implanted valve, it fell into the left ventricle. Immediate surgical intervention was required. The first valve was removed, and surgical aortic valve replacement was successfully performed. In conclusion, we should choose surgical aortic valve replacement for late transcatheter heart valve embolization. Even if we need to treat by catheter intervention, transapical approach may be better.

[Tapia's syndrome following transesophageal echocardiography during an open-heart operation: a case report].

A 67-year-old man presented with hoarseness, dysarthria and deviation of the tongue to the left side the day after the open-heart operation under general anesthesia. Brain MRI demonstrated no causal lesion, and laryngoscope showed left vocal cord abductor palsy, so we diagnosed him with Tapia's syndrome (i.e., concomitant paralysis of the left recurrent and hypoglossal nerve). His neurological symptoms recovered gradually and improved completely four months after the onset. Tapia's syndrome is a rare condition caused by the extra cranial lesion of the recurrent laryngeal branch of the vagus nerve and the hypoglossal nerve, and mostly described as a complication of tracheal intubation. In this case, transesophageal echo probe has been held in the left side of the pharynx, so compression to the posterior wall of pharynx by the probe resulted in this condition, and to the best of our knowledge, this is the first report of Tapia's syndrome due to transesophageal echocardiography during an open-heart operation. This rare syndrome should be considered as a differential diagnosis of dysarthria and tongue deviation after a procedure associated with compression to the pharynx.