[Aortobronchial Fistula after Total Arch Replacement with Stanford Type A Acute Aortic Dissection;Report of a Case].

The patient was a 52-year-old man who had undergone total arch replacement for type A aortic dissection 2 months before. He was admitted to our hospital with hemoptysis due to aortobronchial fistula. We planned to perform 1-stage open chest surgery, but he passed away before the surgery. We considered that earlier open surgery or emergency endovascular stent grafting might have been effective in avoiding this result.

[Isolated Mitral Valve Replacement was Effective in Patient with Hypertrophic Obstructive Cardiomyopathy and Concomitant Mitral Regurgitation;Report of a Case].

This report presents a case of a 68-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) and concomitant mitral regurgitation (MR). Preoperative echocardiography showed stenosis of the left ventricular outflow tract (LVOT) and systolic anterior leaflet motion (SAM) of the mitral valve. She underwent mitral valve replacement( MVR) alone, and obstruction of LVOT was successfully released. Although a septal myectomy is the "gold standard" surgical therapy for HOCM, complications such as heart-block and ventricular septal perforation still remain. It was suggested that in some cases of HOCM complicated with MR, isolated MVR could be considered as the 1st-line surgical therapy.

[Coronary Artery Bypass Grafting and Biventricular Pacing for Severe Heart Failure due to Dilated Cardiomyopathy].

A 57-year-old man was diagnosed with dilated cardiomyopathy and coronary stenosis. His electrocardiogram showed a complete left bundle branch block and a prolonged QRS interval. As appropriate medical therapy improved his symptoms, he did not visit out-patient clinic after discharge. A year later, he presented with exertional chest oppression and was readmitted with severe heart failure. Although medical therapy was provided, his condition did not improve. Left ventricular systolic dysfunction and stenosis of the left anterior descending artery were aggravated. We performed coronary artery bypass grafting and biventricular pacing with surgical epicardial leads, which led to improvement in left ventricular systolic function. We consider that biventricular pacing with surgical epicardial leads is a potential option in cases of open heart surgery requiring cardiac resynchronization therapy for severe left ventricular systolic dysfunction.

[Surgical excision of left atrial myxoma shortly after cerebral embolism;report of a case].

A 48-year-old male visited the emergency room suffering from acute dysarthria and right hemiplegia. Brain magnetic resonance imaging (MRI) revealed multiple cerebral infarctions. Echocardiography showed a mass in the left atrium. He was diagnosed with cerebral embolism due to left atrial myxoma. Open heart surgery immediately after the attack is generally considered contraindicated because of such problems as hemorrhagic infarction or brain edema. However, relapse of embolism may make the condition worse and miss the timing of surgery. Eventually, we electively performed excision of the myxoma 20 days after the onset of cerebral infarction. The postoperative course was uneventful. This is a report about a rare case of open heart surgery shortly after the attack. The indication and the appropriate timing of open heart surgery following cerebral embolism were discussed.

[Aortic root and arch replacement late after ascending aortic replacement for acute aortic dissection; report of a case].

Surgical treatment for acute type A aortic dissection remains controversial, especially when the aortic dissection extends to the aortic root and arch. A 73-year-old woman presented with palpitation. She had previously undergone ascending aorta replacement for acute type A aortic dissection with reinforcement of the proximal and distal aortic stumps using gelatin-resorcinol-formaldehyde (GRF) glue, conducted by a different surgical team 7 years ago. Echocardiography and computed tomography revealed dilatation of both ends of the reconstructed aorta, with aortic valve insufficiency. Hence, we performed Bentall procedure, partial aortic arch replacement, and coronary artery bypass grafting. The postsurgical course was uneventful. Redo operations may be avoidable, if, in the initial operation for acute type A aortic dissection with dissected aortic root and arch, surgery is performed without use of GRF glue for reinforcement of stumps. We recommend to perform the Bentall procedure, partial remodeling procedure, or valve-sparing aortic root replacement for reconstruction of the aortic root and arch replacement for repair of the aortic arch.

Emergency coronary artery bypass grafting for left main shock syndrome.

OBJECTIVE: Acute myocardial infarction (AMI) complicated by cardiogenic shock and left main coronary artery disease (left main shock syndrome) shows high morbidity, and whether early coronary artery bypass grafting (CABG) improves the clinical outcome remains unclear. METHODS: Six consecutive patients (mean age, 61.6 years) with MI complicated by left main shock syndrome underwent emergency CABG. Patients were divided into 2 groups according to the time from MI to reperfusion; within 8 hours in 3 patients and beyond 8 hours in the remaining. Average postoperative peak creatinine kinase (CK) and creatinine kinasemyosin band (CK-MB) levels were recorded, and the ejection fraction (EF) was measured with ultrasound cardiography. RESULTS: Significant differences in postoperative EF and CPK-MB were observed between the 2 groups. The 30-day survival rate was 100%. Five patients left the hospital alive, while 1 died on postoperative day 78. CONCLUSIONS: AMI complicated by cardiogenic shock and left main coronary artery disease can be effectively treated with emergency CABG, with acceptable mortality and morbidity. Emergency CABG for MIs within 8 hours can improve survival in patients with left main shock syndrome.

Hypertrophic cardiomyopathy with apical aneurysm: left ventricular reconstruction and cryoablation for ventricular tachycardia.

This is a case study of a 58-year-old patient with hypertrophic cardiomyopathy, mid-ventricular obstruction, and apical aneurysm who had an episode of syncope due to ventricular tachycardia. Cardiovascular magnetic resonance imaging revealed asymmetrical left ventricular hypertrophy with mid-ventricular obstruction and an apical aneurysm. His coronary angiography was normal, and his ventricular tachycardia was induced by hypertrophic cardiomyopathy without ischemia. Apical aneurysmectomy, left ventricular reconstruction, and cryoablation at the rim of the aneurysm were performed. Fifteen days after the operation, an automatic implantable cardioverter-defibrillator was implanted. The postoperative course was uneventful, and ventricular tachyarrhythmia did not recur during 18 months of follow-up.

Serial changes in epicardial electrograms during and after a coronary artery occlusion.

OBJECTIVE: Suddenly occurring ventricular tachyarrhythmias are a complication during off-pump coronary artery bypass (OPCAB) surgery, potentially leading to the need for conversion to on-pump surgery. We examined serial changes in the spatial dispersion of the electrical activity and refractoriness at the myocardial ischemia border zones during and after coronary occlusion. METHODS: Unipolar epicardial electrograms were continuously recorded from the anterior left ventricle at the border zones during and after a 10-min occlusion of the left anterior descending (LAD) coronary artery in 22 patients undergoing OPCAB. The local electrogram amplitude and local refractoriness were evaluated by the unipolar peak-to-peak amplitude (UPPA) and activation recovery interval (ARI), respectively. The spatial dispersion of the electrical activity and refractoriness were examined using the coefficient of variation of these parameters. RESULTS: No sustained ventricular tachyarrhythmias occurred in any patients. The UPPA dispersion significantly increased up to 5 min after the LAD occlusion and then returned to a nonsignificant level and again increased after reperfusion. The ARI dispersion gradually increased after the LAD occlusion, reached a significantly increased level 3 min after the occlusion, and stayed at a significantly increased level for at least 5 min after the reperfusion. CONCLUSION: There were unique serial changes in the spatial dispersion of the electrical activity and refractoriness at the myocardial ischemia border zones during and after coronary occlusions. Continuous monitoring of these parameters may be useful for predicting the critical electrophysiological conditions prone to the occurrence of ventricular tachyarrhythmias in patients undergoing OPCAB.

Strategies for treatment of acute aortic dissection with involvement of sinus of valsalva.

OBJECTIVE: The aim of this study was to assess the outcome of 3 different surgical approaches for treatment of acute aortic dissection type A (AADA) with involvement of the aortic root. MATERIALS AND METHODS: From November 2002 to December 2007, 51 consecutive patients underwent emergency surgical intervention for AADA with involvement of the aortic root. Supracommissural replacement (SCR) of the ascending aorta was applied to 33 of these patients; 12 cases received a Bentall procedure, and 6 underwent partial remodeling technique in which as much as the dissected aortic root was resected, leaving a rim of 10 mm above the noncoronary annulus and 5 mm above the coronary ostia and commissures. Woven Dacron graft tailored in a scallop-shaped configuration to match the noncoronary sinus was then anastomosed to the proximal aortic stump. RESULTS: Overall hospital mortality was 16% and showed no significant differences among groups. SCR showed a trend toward higher aortic root morbidity. Mean operation time, cardiopulmonary bypass time, and cardiac ischemia time were significantly longer for the Bentall procedure. CONCLUSIONS: In AADA involving aortic root, a partial remodeling technique may be considered the surgical treatment of choice at our institution in suitable patients.

Patch-and-glue sutureless repair for blowout rupture after myocardial infarction: report of two cases.

A blowout cardiac rupture is sudden and dramatic. The most appropriate surgical repair remains controversial. We report our experience with blowout rupture treated by sutureless technique. The two cases were males aged 58 and 79 years respectively. Echocardiography confirmed the diagnosis of cardiac rupture. Resuscitation was continued in the operating suite, and the myocardial tear and necrotic area were covered with two sheets of fibrin tissue-adhesive collagen fleece and an equine pericardial patch secured to the heart surface with biologic glue with the aid of cardiopulmonary bypass. Both patients survived and were discharged from our hospital. One has been doing well for 15 months after surgery and the other remains breathing on his own but otherwise nonreactive for 20 months since. We have adopted a patch-and-glue sutureless technique instituting cardiopulmonary bypass for blowout rupture. Cardioplegic arrest was performed to achieve a bloodless surgical field and maximize glue function. All rupture sites should be covered with a properly large patch. This technique is simple, versatile, and considered to be associated with a favorable outcome.

Patch-and-glue repair in combination with or without direct suture for cardiac rupture after myocardial infarction.

OBJECTIVE: Left ventricular free-wall rupture is a catastrophic event after myocardial infarction. The most appropriate surgical management remains controversial. We have performed a patch-and-glue technique, with or without direct suture and using cardioplegic arrest, to treat postinfarction cardiac rupture. We describe our experiences over a 5-year period, and discuss the optimal surgical repair for each type of rupture. METHODS: Since 2002, we have managed 5 patients with cardiac rupture. Two patients had a blowout rupture, 2 were of the subacute type, and 1 experienced an oozing rupture. There were 3 men and 2 women, with an average age of 76.2 +/- 12.5 years. Echocardiography confirmed the diagnosis in all patients. Two patients underwent a patch-and-glue repair in combination with direct suture, one had an infarctectomy, and the others had a completely sutureless patch-and-glue treatment performed using cardioplegic arrest. RESULTS: All patients survived the initial treatment and were moved to the intensive care unit with complete hemostasis. The 2 patients who were treated in combination with direct suture died of brain death or cardiac failure (mortality rate 40%). The 3 patients who were treated with the patch-and-glue sutureless technique were discharged from our hospital, and are alive 15-27 months after the operation. Two are doing well, and the other is breathing on his own but remains nonreactive. CONCLUSION: We prefer the patch-and-glue sutureless technique even for a blowout rupture. We performed cardioplegic arrest to provide a bloodless surgical field and maximize adhesive function. The whole necrotic area should be covered with a large patch of appropriate size.