[Mitral valvuloplasty utilizing a posterior leaflet patch for healed infective endocarditis; report of a case].

A 63-year-old man was diagnosed as having grade IV mitral regurgitation (MR). Intraoperative examination revealed perforation (13x7 mm) of the anterior mitral leaflet (AML) and prolapse of the posterior mitral leaflet (PML). The prolapsing part of the PML was resected as a rectangle and the AML perforation was covered with this resected PML patch. A Carpentier-Edwards rigid ring (30 mm) was used to secure the mitral valve annulus after suturing the PML. The patient had an uneventful course after surgery and postoperative echocardiography showed no regurgitation.

[Modified Komeda-David operation for postinfarction ventricular septal perforation].

The infarct exclusion technique with a xeno-pericardial patch which Komeda and associates firstly reported in 1990 is one of the best procedure to close ventricular septal perforation. A large patch can protect the perforation and the surrounding weak tissue from the internal left ventricular pressure. However, suturing this large patch to the left ventricular wall through the small incision is not technically easy because of the patch design in the ventricle. We modified the design of the patch. This round shaped bovine pericardial patch was sutured continuously to the left ventricular wall. Then, excessive part of the patch was trimmed to make a corn shape. Finally, the corn shaped patch fit the left ventricular wall naturally.

Real time measurement of heparin concentration during cardiopulmonary bypass.

BACKGROUND: A heparin/protamine titration system for measurement of heparin levels (Hepcon) is promising for efficient anticoagulation during cardiopulmonary bypass (CPB). METHODS: Fifty-seven patients subjected to CPB were divided into two groups, control (n = 24) and Hepcon groups (n = 33). The Hepcon group was further divided into three subgroups according to perfusion temperature. For the control group, conventional administration of an anticoagulant (300 IU/kg of heparin) and reversal protocol (heparin 1: protamine 1) was performed. For the Hepcon group, a heparin dose-response assay directed the initial dose of heparin. Hepcon also determined the dose of protamine by the titration. The initial dose of heparin in the control group (300 IU/kg) was statistically less than that of Hepcon group (360+/-80 IU/kg). RESULTS: In the Hepcon group, the sensitivity to heparin was correlated with coagulation time (r = -0.78) and antithrombin III levels (r = 0.70), and individual difference of sensitivity resulted in a wide range of dosage (160 to 490 IU/kg). A strong correlation was observed between plasma and whole blood concentration of heparin (r = 0.86). However, they did not correlate with ACT values. Perfusion temperature didn't affect the heparin level, but did the ACT value. In the Hepcon group, the dose of protamine was significantly less and adverse events were rare. CONCLUSIONS: In conclusion, whole blood heparin measurements correlated well with plasma heparin concentration. Protamine titration of heparin reduced the dose of protamine and decreased the chance of adverse reactions.

Strategy for balancing anticoagulation and hemostasis in aortocoronary bypass surgery: blood conservation and graft patency.

The minimal effective dose of aprotinin on hemostasis under normothermic perfusion, the influence of anticoagulant therapy on graft patency, and the thromboembolic and hemorrhagic events were investigated after aortocoronary bypass graft operation (CABG). One hundred CABG patients under normothermic perfusion were randomly divided into the following groups: (1) coumadin plus acetylsalicylic acid (ASA) (n=32); no aprotinin used during cardiopulmonary bypass (CPB); (2) minimal-dose, 10(6) KIU during CPB, aprotinin used, followed by ASA and coumadin (n=36); and (3) very low-dose, total of 2x10(6) KIU before CPB and during CPB; aprotinin used; anticoagulation therapy with heparin early after surgery and followed by replacement with ASA and coumadin (n=32). The patency of arterial grafts was 100% in all groups. The patency of vein grafts was 95-98% and there was no difference among the groups. The blood loss was significantly reduced in both aprotinin groups (groups 2 and 3) compared to the coumadin plus ASA group, although no difference existed between the 2 aprotinin groups. Postoperative thrombotic and hemorrhagic events were not observed in any group. From this study, it was concluded that 10(6) KIU aprotinin in pump-prime-only followed by oral ASA and coumadin was the recommendation from the benefit/cost consideration.

[A case report of aortic valve replacement following ruptured aneurysm of the sinus of Valsalva with bicuspid valve].

Only three cases of the combination of bicuspid aortic valve and ruptured aneurysm of the sinus of Valsalva, associated with previously repaired coarctation of aorta, have been reported. A twenty-year-old man with a sudden onset of CHF due to ruptured aneurysm of the sinus of Valsalva underwent intracardiac repair by direct closure of the sinus Valsalva in combination with patch closure of a subarterial VSD. Although, no AR was detected preoperatively, massive regurgitation occurred after the repair due to subsequent failure of aortic valve coaptation in the present of the bicuspid aortic valve, which was not diagnosed preoperatively. Aortic valve replacement with SJM 25 mm was successfully performed.

[Some techniques for the correction of the congenital heart disease with autologous flap].

14 living flaps in 8 children were used to repair for the congenital heart disease, because artificial material and xeno grafts were shrunk in growing children but living flaps were going to glow with children. It were possible to use the living flaps to reconstruct of pulmonary outflow in truncus arteriosus, for septoplasty in partial anomarous of pulmonary venous return and reconstruction of unloofed coronary sinus in endocardial defect with triatriatum and intraatrial tunnel in TCPC or Fontan type operation.

[Mitral valve remodeling using valvuloplasty, chordoplasty and ring annuloplasty].

Degenerative mitral valve disease is a major cause of mitral regurgitation and mitral valve repair has acquired greater importance as a surgical treatment of mitral regurgitation. Since 1991 we have used mitral valve repair to remodel the mitral valve leaflet, chordae tendineae and annulus. The final aim of our mitral valve remodeling technique is to correct the coaptation line of both leaflets. Forty-eight patients who underwent mitral valve repair were analyzed to evaluate the effect of the mitral valve reconstructive technique. We compared the left ventricular function and mitral valvular function by echocardiography and also the left ventricular pressure volume area, which reflects the oxygen consumption of the myocardium, before and after operation. The actuarial survival from all deaths, including one hospital death and one noncardiac death, was 95.8% at 60 months. Three patients have required reoperation because of recurrent regurgitation. Freedom from reoperation at 5 years was 93.8%. Left ventricular end-diastolic (122.3 +/- 45.8-->66.4 +/- 33.8 ml/ m2) and end-systolic volume indexes (39.6 +/- 19.5-->30.1 +/- 18.9 ml/m2) significantly decreased after mitral valve repair, and left ventricular volume overload was markedly reduced. Left ventricular ejection fraction and fractional shortening, which were apparently good before operation, were within the normal range after operation. Left ventricular inflow velocity and mitral pressure gradient were unchanged before and after repair. Mitral valve orifice area was 3.20 +/- 1.08 cm2 and did not show signs of mitral stenosis after repair. The reduction of left ventricular pressure volume area after repair was 53.6 +/- 12.4%, showing marked reduction of the oxygen consumption of the myocardium after successful mitral repair. Left ventricular and mitral valvular function is well preserved after mitral valve remodeling. Mitral valvular function after mitral repair exceeds that of the mitral valve replacement. Mitral valve remodeling procedures are very useful for patients with mitral regurgitation due to mitral valve prolapse.

[Comparison of left ventricular pressure-volume loops measured by two-dimensional echocardiography and a conductance catheter].

A left ventricular pressure volume loop (PV loop) is useful not only in evaluating cardiac function, but also in predicting the postoperative hemodynamic state. There are two methods available for the intraoperative measurement of a PV loop: a conductance catheter and two-dimensional echocardiography. Although the accuracy of conductance catheter is well established for the measurement of ventricular volume, however, the accuracy of echocardiography remains controversy. This paper describes the relationship of parameters including volumes and Emax calculated with each method. Six patients who underwent open heart surgery were included in this study. Comparison of the absolute volumes at four points at the corners of the PV loop showed a Pearson's correlation coefficient of 0.62 (p-value < 0.01). In comparison with the relative volumes at four points which reflect the preoperative to postoperative change ratio, the correlation coefficient was 0.74 (p < 0.01). The correlation coefficients were 0.76 (p = 0.16) and 0.63 (p = 0.29) for the ratio of the end-diastolic and end-systolic volume respectively. Each preload-varying "Emax: out" (r = 0.84, p < 0.01) were highly correlated. As a predictor of cardiac oxygen consumption, each PVA (r = 0.84, p < 0.01) was highly correlated. We conclude that the measurement of left ventricular volume using two-dimensional echocardiography is as reliable as the conductance catheter.

Total cavopulmonary connection without the use of prosthetic material: technical considerations and hemodynamic consequences.

Total cavopulmonary connection with use of an autogenous intraatrial tunnel to create a straight tube between the inferior vena cava and the pulmonary artery was attempted in several types of cardiac anomaly in eight consecutive candidates for the Fontan operation. A small right atrium with an extraordinary location of the inferior vena cava and a short superior vena cava prevented the use of this procedure in two cases. By preserving the crista terminalis and the sinus node and its arteries we prevented the development of postoperative atrial arrhythmias in the short follow-up period, and the P trigger-signal averaged P waves were not different from those of other cardiac anomalies. The proximal stump of the superior vena cava was not incised in any case to enlarge the anastomosis, even when size mismatch between the superior and inferior venae cavae existed, as in a case of bilateral superior venae cavae. Stretching the vessels by approximately 150% was possible and permitted an adequate anastomosis. Cavopulmonary connections via the intraatrial tunnel ensured smooth, nonturbulent, somewhat pulsatile flow without a pressure gradient. We concluded that the creation of an autogenous intraatrial tunnel was possible in many cases without serious complications and that this procedure has potential benefit for the pulmonary circulation in the aspect of pulsatility.

[Mitral valve repair for mitral regurgitation--technical contrivance and its further application].

To evaluate the mitral reconstructive technique from the pathological and surgical points of view, 33 consecutive cases were analyzed. Eighteen patients (54.5%) were men, and the mean age was 40.9 +/- 19.8 (range 5 to 72 years). Ten patients (30.3%) had atrial fibrillation. The causes of mitral regurgitation were torn chordae tendinae in 17, elongated choradae tendinae in 14, annular dilatation in 8, papillary muscle dysfunction in 2, and congenital cleft in 4. The mitral regurgitation was due to prolapse of the anterior leaflet in 16, prolapse of the posterior leaflet in 10, and prolapse of both leaflets in 5. Resection and reconstruction of the leaflet was performed on anterior leaflet in 15, and on posterior leaflet in 15. The anterior mitral cleft was sutured in 3. The newly contrived wrapping and shortening chordoplasty was performed on anterior leaflet in 6, on posterior leaflet in 3, and on both leaflets in 2. Two patients had replacement of artificial chordae tendinae with EPTFE suture. Commissuroplasty was performed at anterolateral commissure in 5, at posteromedian commissure in 15, and at both commissures in 5. Thirty patients with dilated annulus underwent ring annuloplasty by Carpentier ring. There was no hospital death. Two patients required mitral valve replacement for redeveloping mitral regurgitation 2 weeks and one year after initial operation. All patients were in NYHA functional class I after surgery. The Doppler echo cardiographic study revealed no mitral regurgitation in 27, mild or trivial in 3, and moderate in 3. LVEDVI and LVESVI significantly decreased, and left ventricular volume overload was markedly reduced.

[Direct implantation of the left coronary artery in BWG syndrome--sparing the shortage of distance with pulmonary arterial wall].

Anomalous origin of the left coronary artery (ALCA) arising from the pulmonary artery is a rare anomary, and causes myocardial infarction and death in children. Direct implantation of ALCA to the aorta was performed in the 6-year-old female patient. A large button of pulmonary arterial wall resected with ALCA could spare the shortage of the distance between the aorta and the ALCA. Postoperative catheterization displayed non-stenotic left coronary artery. Left ventricular function assessed by echocardiography showed improvement. Cold area in early stage postoperative myocardial imaging disappeared one year after the surgery, which suggested the hibernation of the preoperative myocardium.

[New configuration of right ventricular dynamic cardiomyoplasty by latissimus dorsi for hypoplastic right ventricle].

UNLABELLED: The purpose of this experimental study is to evaluate the efficacy of linear-type right ventricular (RV) dynamic cardiomyoplasty in a setting of patch enlargement model for hypoplastic RV. In 6 puppies (6-8 kg), under a cardiopulmonary bypass (CPB), RV free wall and septal traveculation were resected and replaced with large pericardial patch, simulating RV patch enlargement of hypoplastic RV. A pedicled left LD, anchored to 3rd rib, wrapped onto the RV patch in parallel to RV long axis, while LD fixed to only RV diaphragma surface without wrapping LV surface. After the termination of CPB, LD flap was synchronously paced at 1:1 ratio with cardiac beat with a trained-pulse stimuli (10-25 Hz). RV performance was tested by RV function curve (RVSWI vs CVP) and RV pressure-volume relationship (ESPVR) assessed by conductance catheter. RESULTS: LD graft stimuration showed significant augmentation of PAP (145 +/- 21%), PA flow (152 +/- 21%) and AP (128 +/- 23%) at CVP of 10 mmHg. RV function curve and ESPVR confirmed dramatical augmentation of RV performance by graft stimulation, which was identical to preoperative normal RV function even at the low CVP range. CONCLUSIONS: Linear LD myoplasty after patch enlargement of RV may viable surgical option for hypoplastic RV.

[The effect of mitral valve repair and postoperative mitral valve function].

Thirty-six patients who underwent mitral valve repair were analyzed to evaluate the effect of mitral valve reconstructive technique. The final aim of this technique is to true up the coaptation line of both leaflets. Resection and reconstruction of the leaflet was performed on anterior leaflet in 11, on posterior leaflet in 12, and on both leaflets in 5. The newly contrived wrapping and shortening chordoplasty was performed on anterior leaflet in 6, on posterior leaflet in 3, and on both leaflets in 2. Two patients had replacement of artificial chordae tendinae with EPTFE suture. Commissuroplasty was performed at anterolateral commissure in 5, at posteromedian commissure in 15, and at both commissures in 5. Thirty patients with dilated annulus underwent ring annuloplasty with Carpentier ring. LVEDVI and LVESVI significantly decreased after mitral valve repair, and left ventricular volume overload was markedly reduced. Mitral valve orifice area was 3.23 +/- 1.14 cm2 and did not show the sign of mitral stenosis after repair. Left ventricular pressure volume area, which reflects the oxygen consumption of the myocardium, was markedly reduced after successful mitral repair.

[One and one half ventricle repair for pure pulmonary atresia--a case report].

One and one half ventricle repair consisting of the Glenn operation and the right ventricular outflow tract reconstruction was performed in a 4-year-old boy. The diagnosis of this patient was pure pulmonary atresia. He had undergone Brock's operation, Blalock-Taussig shunt and a central shunt at neonatal period. At the time of one and one half ventricle repair, the connection between the superior vena cava and the right atrium was left open. Although the RVEDV was 34.3% of normal, the topology of the right ventricle was tripartite. At three months after one and one half ventricle repair, RVEDV increased up to 52.7% of normal. This data suggests that a further definitive surgery, i.e., complete biventricular repair could be applicable in the future.

[Reoperation for tetralogy of Fallot].

We experienced 6 cases of reoperations after the intracardiac repair of tetralogy of Fallot between Nov. 1991 and Feb. 1994. Mild to moderate left to right shunts and pulmonary stenosis were observed in all patients. Pulmonary insufficiency was detected by echocardiography in all patients but one. All diagnosed residual problems were repaired at this time of operations. Cardiac parameters such as CTR, left and right ventricular dimensions were all improved in the association of NYHA improvement. The % changes of ventricular dimensions were influenced by the severity of shunt and pressure gradient. Perioperative pressure-volume loops demonstrated that the degree of left to right shunt correlated with the % changes of stroke work and pressure-volume area, which were considered to determine the myocardial oxygen demand. Thus the repairs reduced certainly the oxygen demand of the heart. We concluded that the residual complications could be safely handled by the reoperation and the repairs were extremely meaningful for the quality of life in patients.