[A Huge Aortic Root Aneurysm Nineteen Years After Aortic Valve Replacement:Report of a Case].

We report a case of huge aortic root aneurysm 19 years after aortic valve replacement. A 58-year-old woman was referred to us for aortic root dilatation. She underwent aortic valve replacement with mechanical valve due to severe aortic regurgitation of tricuspid aortic valve 19 years ago. We performed graft replacement of aortic root preserving prior mechanical prosthetic valve. Histological examination of aneurysm showed myxomatous change in medial layer. Aortic root dilatation after aortic valve replacement is caused by bicuspid valve, aortic dissection, Marfan syndrome, tissue disorder disease, aortitis, and dilated Valsalva sinus at the time of prior operation. It is important to follow-up a patient for root dilatation after aortic valve replacement.

A functional evaluation of cerebral perfusion for coronary artery bypass grafting patients.

We evaluate the utility of providing a pulsatile blood flow by applying off-pump coronary artery bypass grafting (CABG) or intra-aortic balloon pumping (IABP) with conventional CABG to prevent perioperative stroke in patients with cerebral hypoperfusion on single-photon emission-computed tomography (SPECT). A total of 286 patients underwent isolated CABG with a cerebral magnetic resonance angiography (MRA) evaluation between 2006 and 2015. Seventy-five had significant stenosis and/or occlusion of craniocervical vessels; the other 211 had no significant stenosis. Cerebral SPECT was performed for 49 (SPECT group) of the 75 patients. The SPECT group was further divided into a normal perfusion (NP) (n = 37); and a hypoperfusion (HP) (n = 12). In the present study we compared the NP group and the 211 patients with no significant stenosis (as a control group) to the HP group. No strokes occurred in the HP group, and 1 stroke occurred at the time of operation in the control group. Postoperative stroke within 30 days occurred in 3 patients in the control group; the difference was not statistically significant. The long-term stroke-free rates of the HP and Control group did not differ to a statistically significant extent. The functional evaluation of cerebral perfusion by SPECT is important when patients have significant stenotic lesions on cerebral MRA. Maintaining an adequate pulsatile flow by off-pump CABG or IABP with conventional CABG will help prevent perioperative stroke, even if cerebral hypoperfusion is detected by SPECT.

[Giant Right Coronary Artery Aneurysm Causing Acute Myocardial Infarction;Report of a Case].

We report a case of giant right coronary artery aneurysm causing acute myocardial infarction. A 59-year-old man presented with syncope and referred to our hospital in ambulance. Electrocardiogram showed acute myocardial infarction of the right coronary artery, and emergent coronary angiography was performed. Angiography confirmed a giant coronary artery aneurysm in the mid-portion of the right coronary artery. He underwent aneurysmectomy and coronary artery bypass grafting to the posterior descending artery. Spontaneous rupture of a giant coronary artery aneurysm is rare, but critical condition such as acute myocardial infarction or fistula to heart chamber can occur. Surgical intervention is indicated for a giant coronary artery aneurysm to prevent possible life-threatening consequences in the future.

[Intra-operative Acute Aortic Dissection during Aortic Root Reimplantation and Mitral Valve Reconstruction Surgery in a Patient with Marfan Syndrome;Report of a Case].

In patients with Marfan syndrome, cardiovascular complication due to aortic dissection represents the primary cause of death. Iatrogenic acute aortic dissection during cardiac surgery is a rare, but serious adverse event. A 51-year-old woman with Marfan syndrome underwent elective aortic surgery and mitral valve reconstruction surgery for the enlarged aortic root and severe mitral regurgitation. We replaced the aortic root and ascending aorta based on reimplantation technique. During subsequent mitral valve reconstruction, we found the heart pushed up from behind. Trans-esophageal echocardiography revealed a dissecting flap in the thoracic descending aorta. There was just weak signal of blood flow in the pseudolumen. We did not add any additional procedures such as an arch replacement. Cardio-pulmonary bypass was successfully discontinued. After protamine sulfate administration and blood transfusion, blood flow in the pseudolumen disappeared. The patient was successfully discharged from the hospital on 33th postoperative day without significant morbidities.

Left Ventricular Outflow Tract Obstruction of Double Valve Re-Replacement Using Bioprosthesis.

We present a case of left ventricular outflow tract (LVOT) obstruction after double valve re-replacement with bioprostheses. A 72-year-old man, who had undergone double valve replacement (DVR) with bioprosthetic valves 9 years previously, underwent re-replacement of valves because of structural valve deterioration. However, owing to LVOT obstruction related to the bioprosthesis in the mitral position, acute pulmonary edema occurred immediately after surgery. LVOT obstruction was diagnosed by emergent cardiac catheterization. So prompt re-replacement surgery using a mechanical prosthesis was performed.

Impact of skeletal muscle mass on clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

Low skeletal muscle mass is one of the components of sarcopenia. However, the prognostic impact of skeletal muscle mass on clinical outcomes in patients after transcatheter aortic valve replacement (TAVR) remains unclear. Therefore, we assessed the impact of skeletal muscle mass on future cardiovascular events in patients undergoing TAVR. We enrolled 71 consecutive patients who underwent TAVR for symptomatic severe aortic stenosis. We applied bilateral psoas muscles as an indicator of skeletal muscle mass. Psoas muscle volumes were measured from the origin of psoas at the level of the lumbar vertebrae to its insertion in the lesser trochanter on three-dimensional computed tomography datasets. Psoas muscle mass index (PMI) was calculated as psoas muscle volume/height2 (cm3/m2). According to the median value of PMIs (79.8 and 60.0 cm3/m2 for men and women), the enrolled patients were divided into two groups. During the follow-up, 11 (31.4%) patients in low PMI group and 4 (11.1%) in high PMI group experienced major adverse cardiovascular events (MACE) defined as a composite of death from any cause, myocardial infarction, heart failure hospitalization, and stroke. The proportion of MACE-free survival was significantly lower in low PMI group (log-rank P = 0.033), mainly due to the difference of hospital readmission for congestive heart failure. On multivariate Cox proportional hazard analysis, PMI remained an independent negative predictor of MACE [hazard ratio 0.95 (95% confidence interval 0.92-0.98, P = 0.002)]. In conclusion, low skeletal muscle mass independently predicted MACE in patients undergoing TAVR.

Stent graft implantation combined with coil embolization and external-internal iliac artery bypass surgery: report of a case.

A 73-year-old male patient was found to have an abdominal aortic aneurysm complicated with bilateral common iliac artery aneurysms. He also had hepatitis C, chronic liver cirrhosis (Child-Pugh class B), a rupture of esophageal varices, hepatocellular carcinoma, and intractable ascites. The functions of other systemic organs were also impaired. We first performed a right internal iliac artery coil embolization prior to stent graft implantation combined with a left external-internal iliac artery bypass. These additional procedures allowed for safe treatment with stent graft implantation, without any serious complications.

Novel Trigone-Based Sizing Method for Mitral Ring Annuloplasty.

BACKGROUND: We devised a novel trigone-based sizing method, setting the trigones at one-quarter of the annular circumference, and used it for mitral annuloplasty in patients with mitral regurgitation (MR). METHODS: Between 1999 and 2017, 436 patients with degenerative (n = 192), nonischemic functional (n = 124), or ischemic (n = 120) MR underwent mitral valvuloplasty at our institution using an incomplete ring. The intertrigonal distance and prerepair and postrepair annular diameter were measured. Then the diameters predicted from body surface area, the intertrigonal distance, and the ratios of these diameters to observed data were computed. We investigated the influence of these measurements on MR recurrence, transmitral pressure gradient, and systolic anterior motion. RESULTS: Initial repair was successful in 433 patients (99%), but 3 patients with systolic anterior motion and MR required conversion to valve replacement. After 1, 5, and 10 years (mean follow-up, 6.3 years), the rate of freedom from grade 2 or higher recurrent MR was 96%, 92%, and 86% in the degenerative group, 99%, 97%, and 90% in the nonischemic functional group, and 95%, 90%, and 79%, respectively, in the ischemic group (P = .052). The observed/body surface area predicted diameter ratio was negatively correlated with the mean transmitral pressure gradient (mm Hg); 12.3 - 8.2 × (ratio) (R = -0.37, P < .001), despite a smaller ratio (<0.9) not being associated with less recurrence of MR. In the degenerative group, systolic anterior motion developed in 7 of 71 patients (10%) with an observed/intertrigonal distance predicted diameter ratio of less than 0.9 (P < .001). CONCLUSIONS: Our trigone-based sizing method achieved satisfactory control of MR, while avoiding functional mitral stenosis and systolic anterior motion.

Pericardial Sandwich Technique for End-to-End Anastomosis of Artificial Graft.

End-to-end anastomosis between prosthetic grafts seems technically easy; however, bleeding from the needle hole or at the site of anastomotic discrepancy can be problematic. The pericardial sandwich technique helps to resolve this issue. The grafts are generally anastomosed to each other with a continuous suture, and a strip of autopericardium is sandwiched circumferentially between the two grafts. Although this anastomosis involves a special technique, it is not intricate. The pericardium effectively covers the needle hole and gap between the grafts. This method is useful for large-vessel surgery, especially in patients with coagulopathy.

Limitations of retrograde continuous tepid blood cardioplegia for myocardial remodeling.

OBJECTIVE: We assessed potential limitations of retrograde continuous tepid blood cardioplegia (RCTBC) for myocardial remodeling, represented by hypertrophied and/or dilated myocardium in patients with severe cardiomyopathy following single aortic valve replacement. METHODS: The study was conducted on 91 patients who underwent initial single aortic valve replacement with tepid cardiopulmonary bypass (CPB) and RCTBC. Based on the postoperative maximum creatine phosphokinase (max CPK)-MB level, the patients were allocated to Group H (>/=100 IU/mL) with severe cardiomyopathy or Group L (<100 IU/mL) to make intergroup comparisons of preoperative, intraoperative, and postoperative parameter values. RESULTS: Preoperative measurements were as follows: pressure gradient between left ventricle and aorta (DeltaPG), 92.8+/-46.2 mmHg in Group H and 57.9+/-41.6 mmHg in Group L (p<0.01); implanted valve size, 21.0+/-2.2 mm in Group H and 22.8+/-2.2 mm in Group L (p<0.01); left ventricular end-diastolic volume (LVEDV), 155.7+/-73.3 mL in Group H and 224.3+/-101.5 mL in Group L (p<0.01). The rate of RCTBC flow rate increase did not differ between the groups (17.6% in Group H and 20.7% in Group L), while the rate of concomitant use of optional antegrade coronary perfusion was significantly lower in Group H (25%) than in Group L (37%) (p<0.05). Pre- and post-perfusion lactic acid levels in the myocardial protection solution measured every 30 min after aortic cross clamping were higher in Group H than in Group L. CONCLUSION: The study suggests preoperative high DeltaPG, small aortic root diameter, and low LVEDV, namely, concentrically hypertrophied myocardium, as risk factors for severe cardiomyopathy after RCTBC. RCTBC in patients with any risk factor should be accompanied by an increase in initial continuous perfusion flow and/or aggressive use of intermittent antegrade coronary perfusion.

Successful surgical repair of an infectious thoracic aortic pseudoaneurysm accompanied by aortobronchopulmonary fistula and advanced hepatic dysfunction without assisted circulation.

The patient was a 59-year-old female. Because of massive hemoptysis, she was brought to our emergency center by ambulance. Thoracic computed tomography led to a diagnosis of an infectious thoracic aortic pseudoaneurysm accompanied by an aortobronchopulmonary fistula. Emergency surgery followed. Also noted was an advanced hepatic dysfunction, assessed as Child-Pugh score B, caused by an alcoholic liver disease. A localized affected area made it possible for us to perform an aneurysmectomy using a temporary bypass rather than assisted circulation. A patch plasty using expanded polytetrafluoroethylene completed the procedure. Streptococcus agalactiae (GBS) was detected in a sample obtained during the surgery from an abscess located in the aneurysm. The patient made satisfactory postoperative progress and left the hospital walking unaided on the 36th postoperative day.

An aortic root pseudoaneurysm that developed after implantation of a rectus abdominis muscle flap to treat an MRSA mediastinitis: a case report.

The occurrence of mediastinitis following synthetic vascular replacement surgery is still associated with an unfavorable prognosis in the treatment of thoracic aortic diseases. This time we report a Bentall procedure that we re-performed to treat an aortic root pseudoaneurysm, which developed after a postoperative mediastinitis. This followed the first Bentall procedure, which was treated by debridement of the focus of infection, continuous lavage, and a two-step rectus abdominis muscle flap implantation. Implantation of a rectus abdominis muscle flap is effective in controlling infection in the treatment of mediastinitis after heart surgery. However, after synthetic vascular replacement surgeries have been performed to treat aortic diseases, especially after aortic root reconstruction surgery, which puts stress on the anastomotic site, consideration should be given regarding the development of hemorrhages and pseudoaneurysms as a result of infection-induced tissue fragilization.

Study of coronary artery bypass using the PAS-Port device: assessment by multidetector computed tomography.

OBJECTIVE: The use of automatic anastomotic devices in coronary artery bypass grafting surgery is associated with lower patency rates in comparison to conventional anastomosis methods. This is thought to be caused by graft curvature occurring after closing of the chest wall. METHODS: We evaluated 39 grafts in 28 patients who underwent off-pump coronary artery bypass surgery using the PAS-Port. After surgery, the proximal anastomotic angle of each stent, graft morphology, and patency were evaluated with axial and sagittal views. RESULTS: The angle for the left anterior descending coronary artery segment was relatively obtuse on the left side of the ascending aorta, and the graft loop formation was not necessary. The angle for the left circumflex coronary artery segment was significantly acute for anastomosis from the upper left side of the ascending aorta. Because grafts are under the constraints of a large loop, graft length tended to become easily excessive or deficient. The angle for the right coronary artery segment was relatively obtuse. The space on the right side of the heart was so narrow that in some cases we had difficulty setting out the appropriate graft location to prevent graft curvature. No bending or stenosis was present in any graft, showing a patency rate of 100%. CONCLUSION: The short-term results of coronary bypass grafting using PAS-Port are satisfactory.