Multiple small tumor formation on both surfaces of the aortic valve cusps in Epstein-Barr virus-associated T/NK-cell lymphoproliferative disease: a case report.

A 41-year-old woman presented acute cerebral infarction. Transesophageal echocardiography revealed multiple masses only on both surfaces of the aortic valve cusps. There was no primary lesion outside the heart according to various examinations. After treatment for cerebral infarction, we replaced the aortic valve instead of preservation because the intraoperative histological examination reported that malignancy was highly suspected. Contrary to the rapid frozen section diagnosis, histological and immunohistochemical examinations failed to exhibit malignancy. The tumors were composed of atypical large lymphoid cells and they were assessed to be related to T-/natural killer-cells. Furthermore, Epstein-Barr virus related markers were also positive. Her three-year postoperative course was uneventful without chemotherapy. We report an extremely rare case of Epstein-Barr virus-associated T-/natural killer-cell lymphoproliferative disease which formed multiple small tumors on both surfaces of the aortic valve.

10-year results of On-X bileaflet mechanical heart valve in the aortic position: low target INR regimen in Japanese.

OBJECTIVES: This study was designed to establish clinical outcomes after aortic valve replacement (AVR) with On-X bileaflet mechanical heart valve. METHODS: Between 2006 and 2014, AVR was performed to 686 patients. Of them, 78 patients using On-X valve were enrolled. The mean age was 65 ± 11 years (ranged 33-85); 65% were men; and 81% were in sinus rhythm preoperatively. Calcific or degenerative tricuspid aortic valve was present in 73%. Concomitant procedures included coronary artery bypass grafting (22%), Bentall (8%), mitral valve procedure (3%) and other (9%). They postoperatively received lower dose warfarin [international normalized ratio (INR), 1.5-2.0] and 100 mg aspirin daily. The follow-up duration averaged 5 years (386.6 patient-years). The follow-up rate was 97.3%. RESULTS: In-hospital mortality rates were 3.8% (n = 3). Late mortality rates were 2.6% per patient-years (n = 10). Five-year Kaplan-Meier survival rates were 84%. Freedom from major adverse valve-related stroke and cerebral bleeding events was 93.3% (n = 5, 1.29% per patient-years) and 98.6% (n = 1, 0.26% per patient-years, mild subdural hematoma). The incidence of stroke was two patients of transient ischemic attack, two patients of paralytic event, one patient of asymptomatic stroke (self-interruption of anticoagulation). The median INR was 1.92 ± 0.53, ranged from 1.00 to 8.98 (n = 1181) and 51% of all measured INR values were in the therapeutic range of 1.5-2.0. CONCLUSIONS: AVR using On-X valve with low target INR regimen and low-dose aspirin resulted in a significantly low risk of bleeding.

Late rupture of artificial neochordae associated with hemolytic anemia.

A 63-year-old man, status post-mitral valve repair for severe mitral regurgitation secondary to ruptured chordae of the anterior leaflet, was admitted seven years after surgery because of a recent history of hematuria. A new apical pansystolic murmur was audible. Hemoglobin level was 5.7 g/dL. Results of other hematologic studies and a peripheral blood smear were indicative of mechanical hemolysis. Transesophageal echocardiography showed a high-velocity jet of mitral regurgitation that directly collided with the annuloplasty ring. At re-operation, one of the artificial neochordae to A2 and A3 segments was found to be disrupted. The mitral valve was replaced with a 33/31 mm On-X valve. Hemolytic anemia disappeared immediately after surgery. Although mitral valve repair with artificial neochodae has been shown to have long-term durability, it should be recognized that artificial neochordae may rupture a long time after mitral valve repair. Also, although hemolytic anemia is known as an early complication after mitral valve repair, it is worth knowing that hemolytic anemia may occur as a late complication after mitral valve repair. Continuous long-term monitoring of the patients after mitral valve repair is recommended. .

A reoperation of thrombosed On-X valve detected by multidetector-row computed tomography.

A 62-year-old female patient underwent mitral valve replacement with a 31/33-mm On-X valve for ischemic mitral valve regurgitation. Three months later, transthoracic echocardiography incidentally showed a blocked leaflet with 6 mmHg of mean pressure gradient and 2.4 cm(2) of mitral valve orifice area. Transesophageal echocardiography could not detect thrombus. Electrocardiographically gated multidetector-row computed tomography (MDCT) clearly demonstrated a blocked leaflet in the close position and thrombus (2 cm in length, 0.4 cm(2) in area) attached onto the atrial aspect of the leaflet. These findings observed by MDCT were confirmed at reoperation. MDCT was useful diagnostic method for visualizing prosthetic valve thrombosis.

Mid-term results of 17-mm St. Jude Medical Regent prosthetic valves in elder patients with small aortic annuli: comparison with 19-mm bioprosthetic valves.

This study was designed to compare the mid-term outcomes after aortic valve replacement (AVR) between 17-mm mechanical heart valves (MV) and 19-mm bioprosthetic valves (BV) in elderly patients with small aortic annuli. Between 2000 and 2011, 127 consecutive patients (mean age 79 years; 87 % female) underwent AVR for aortic valve stenosis with a small aortic annulus. 19-mm BV (n = 67) was implanted. When the 19-mm BV did not fit the annulus, 17-mm St. Jude Medical Regent prosthetic mechanical valve (n = 60) was used instead of an aortic root-enlargement procedure. The follow-up rate was 94.0 % in the BV group, and 98.5 % in the MV group. No significant differences in survival rate and valve-related complications were found between the 2 groups. In-hospital mortality rates were 1.5 % (n = 1) in the BV group and 5.0 % (n = 3) in the MV group. Late mortality rates were 3.9 % per patient-years (p-y; n = 8) in the BV group, and 6.0 % per p-y (n = 10) in the MV group. Five-year Kaplan-Meier survival rates were 62 % in the BV group, and 72 % in the MV group (log-rank P = 0.280). Freedom from major adverse valve-related stroke and cerebral bleeding events was 92.5 and 98.5 % in the BV group, and 94.7 and 100 % in the MV group. AVR using 17-mm MV in elder patients with small aortic annuli provided equivalent mid-term clinical results to that with 19-mm BV.

Evaluation of advancing the standard valve dysfunction by multidetector-row CT.

We evaluated the diagnostic usefulness of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve dysfunction (PVD) of an ATS valve. Twenty-four patients underwent MDCT following echocardiography and cineradiography. Echocardiography and cineradiography showed normal valve function in 17 patients and PVD in 7. PVD included aortic prosthetic valve obstruction in 4 patients, an aortic annular aneurysm with paraprosthetic regurgitation in one, and a blocked leaflet in the mitral position in 2. Among the 7 patients, 5 received reoperation after MDCT. MDCT revealed a subprosthetic mass in all 5 patients with PVD and in 4 patients with normal valve function in the aortic position. In addition to a subprosthetic mass, an annular aneurysm was found in one. Valvular masses were detected in 2 patients with mitral PVD. At reoperation, subprosthetic pannus in the aortic position was detected in 2 patients, subprosthetic pannus and annular aneurysm with paraprosthetic leaks in one, and mitral valve thrombosis in 2. These findings confirmed at reoperation matched to the findings observed on MDCT. The mean CT attenuation of the subprosthetic mass in 6 patients was 152 ± 12 HU and that of the subprosthetic pannus in 3 patients was 163 ± 17 HU. CT attenuation of the thrombus in the mitral valve in the 2 patients was 60 and 99 HU. Our study demonstrates that MDCT is a valuable and reliable diagnostic technique for PVD in an ATS valve and that MDCT may identify an abnormality causing PVD.

Diagnosis of structural deterioration in an aortic bioprosthetic valve by multidetector row computed tomography: report of a case.

A 32-year-old female patient presented with shortness of breath. The patient had received aortic valve replacement with a 25-mm bioprosthetic valve at the age of 22, and had had two babies, postoperatively. Ten years later, echocardiography showed the calcifi ed bioprosthetic valve with a high peak pressure gradient (70 mmHg) and a reduced valve orifice area (0.46 cm(2)). Electrocardiographically gated multidetector row computed tomography (ECG-gated MDCT) clearly demonstrated calcifi ed bioprosthetic cusps with reduced mobility, and the valve orifi ce area was measured to be 0.64 cm(2) by direct planimetry. These fi ndings observed by ECG-gated MDCT were confi rmed at reoperation. This is the fi rst reported reoperation case of aortic structural valve deterioration clearly visualized by ECG-gated MDCT.

Evaluation of prosthetic valve obstruction on electrocardiographically gated multidetector-row computed tomography--identification of subprosthetic pannus in the aortic position.

BACKGROUND: This study was performed to evaluate the diagnostic role of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve obstruction (PVO) in the aortic position. METHODS AND RESULTS: Between 2002 and 2006, 9 patients were diagnosed with PVO of an aortic bileaflet mechanical valve based on echocardiographic and cineradiographic criteria. These 9 patients were examined using MDCT before replacement of the mechanical valve, and intraoperative findings were compared to morphologic periprosthetic abnormalities observed on MDCT. CT attenuation (Hounsfield units; HU) of the periprosthetic abnormalities was measured to investigate the underlying cause of the PVO. MDCT showed subprosthetic masses extending beyond the prosthetic ring into the orifice of the valve. At reoperation, presence of subprosthetic pannus was confirmed in all of the 9 patients, but no periprosthetic thrombus was found. The mean CT attenuation of the subprosthetic pannus was 170 HU, and it was significantly greater than that obtained from the interventricular septum (108 HU; P<0.0001). CONCLUSIONS: MDCT can be used to clearly visualize subprosthetic pannus causing PVO and the mean CT attenuation of subprosthetic pannus is significantly higher than that of the interventricular septum on MDCT.

Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery.

BACKGROUND AND PURPOSE: Postoperative bowel dysfunction is still a major unsolved problem following transperitoneal abdominal aortic surgery. We conducted this study to establish if gum chewing during the postoperative period promotes recovery of bowel function following abdominal aortic surgery. METHODS: The subjects were 44 patients who underwent elective abdominal aortic surgery. The patients were allocated to a control group (n = 21), who received standard postoperative care, or a "gum group" (n = 23), who received standard postoperative care and were also given gum to chew three times a day from postoperative day (POD) 0-5. RESULTS: The patient characteristics, intraoperative, and postoperative care were equivalent in both groups. Flatus was passed on POD 1.49 in the gum group and on POD 2.35 in the control group (P = .0004) and the time to oral intake was 3.09 days in the gum group and 3.86 days in the control group (P = .023). The number of days to full mobilization in the hospital room was 3.35 versus 5.59 for the gum and control groups, respectively (P < .0001). CONCLUSIONS: Gum chewing enhances early recovery of bowel function following transperitoneal abdominal aortic surgery. Moreover, it is a physiologically sound, safe, and an inexpensive part of the postoperative care.

Concurrent submitral left ventricular aneurysm and an aneurysm of the sinus of valsalva: report of a case.

We herein describe a rare case of a concurrent submitral left ventricular (LV) aneurysm and an aneurysm of the sinus of Valsalva in a 65-year-old Japanese woman. The patient had a history of mitral valve replacement (MVR) for mitral regurgitation caused by a submitral LV aneurysm at the age of 58. At the time of the MVR, the orifice of the submitral LV aneurysm without thrombi was beneath the posterior leaflet, but surgical repair of the submitral LV aneurysm was not attempted. Although the patient was asymptomatic, when she underwent an echocardiogram at 65 years of age an aneurysm of the noncoronary sinus of Valsalva was detected. However, echocardiography performed before the initial operation had shown that the aneurysm of the sinus of Valsalva was coexistent with the submitral LV aneurysm. Since the submitral LV aneurysm revealed no progressive enlargement during the 7 years, patch closure of the aneurysm of the sinus of Valsalva alone was successfully performed.

New design bioprosthesis: early outcome of Carpentier-Edwards PERIMOUNT Magna in the small annular aortic position.

The Carpentier-Edwards PERIMOUNT (CEP) Magna (Edwards Lifesciences, Irvine, CA, USA) is a newly developed bioprosthesis with an improved cuff design that allows its implantation into the smaller aortic annulus. We evaluated the hemodynamic performance of the CEP Magna for smaller aortic annulus cases. Patients who underwent aortic valve replacement for aortic stenosis receiving a Magna 19 mm (n = 13), were compared with a standard CEP (n = 19). In the 19-mm series, the real annular size was significantly smaller in the Magna than the standard (21.1 ± 0.8 vs. 19.8 ± 0.8 mm, p = 0.007). The Magna was significantly superior with respect to effective orifice area index (EOAI) at postoperative 3 months; however, no significant difference was seen in other factors (peak pressure gradient, left ventricular mass index, ejection fraction). At postoperative 3 months, despite the lack of statistical significance, the incidence of patient-prosthesis mismatch (PPM) was lower with the Magna. Using the same label size, the Magna can be implanted in a smaller aortic annulus with performance comparable with or better than hemodynamic performance with the standard CEP. The Magna is a useful prosthesis for the small aortic annular patient.

Treatment for mechanical valve thrombosis in the right heart: combined pharmacological and mechanical thrombolysis.

We report clinical results of combined pharmacological and mechanical thrombolysis for mechanical prosthetic valve thrombosis (PVT) in the right heart. Between January 1992 and December 2008, combined thrombolysis, which consisted of an intravenous infusion of urokinase together with mechanical disruption of thrombus in a prosthetic valve by temporarily increasing the cardiac pacing rate, was performed in three patients with four cases of mechanical PVT in the right heart. The prosthetic valve in all three patients was a bileaflet mechanical valve, and was located in the tricuspid position in two patients and in the pulmonary position in the remaining patient. PVT was diagnosed by echocardiography and cineradiography. Thrombolysis was successful in all four cases in the three patients, and no hemorrhagic complications or clinically symptomatic pulmonary embolisms were observed. Mechanical disruption of thrombus using a pacemaker appears to be an effective adjunctive modality to thrombolysis with fibrinolytic agents for PVT in the right heart. Combined pharmacological and mechanical thrombolysis may improve success rates and reduce the time required for thrombolysis of PVT.

Obstruction of St. Jude medical valves in the aortic position: plasma transforming growth factor type beta 1 in patients with pannus overgrowth.

The study investigated the hypothesis that plasma transforming growth factor type beta 1 (TGF-beta1) initiated pannus overgrowth in cases with aortic prosthetic valve dysfunction (PVD). Patients with obstruction of an aortic St. Jude Medical valve in 26 cases (PVD group) and without obstruction in 48 cases (control group) were studied. Plasma TGF-beta1, the intensity of the prothrombin time-international normalized ratio (PT-INR), and the interruption of an oral anticoagulant medicine were conducted. Plasma TGF-beta1 levels in the PVD group (87.7 +/- 29.2 ng/mL) were significantly higher (P < 0.05) than in the control group (73.7 +/- 25.2 ng/mL). The interruption of an oral anticoagulant medicine in 54% of the PVD group versus 12% of the control group was identified (P < 0.001). The mean value of the PT-INR in the PVD group (1.75 +/- 0.30) and control group (1.75 +/- 0.30) was not significantly different (P = 0.82). In conclusion, elevated levels of plasma TGF-beta1 may play a role in pannus overgrowth.

Coronary artery bypass grafting in patients with pulmonary aspergillosis.

Cardiovascular surgery in patients with pulmonary aspergillosis has been rarely reported. Coronary artery bypass grafting (CABG) for three cases of angina pectoris with pulmonary aspergillosis was successfully performed. Patients were discharged from our hospital without any complications of invasive Aspergillus cardiovascular infection. Careful perioperative management for preventing pulmonary complications is important.

Postoperative left ventricular mass regression after aortic valve replacement for aortic stenosis.

BACKGROUND: Small valve size and prosthetic patient mismatch are both considered to have harmful effects on residual left ventricular hypertrophy after aortic valve replacement for aortic stenosis. In general, it is believed that the effective orifice area index of the prosthesis must not be less than 0.85 cm(2)/m(2) in order to avoid prosthetic patient mismatch. On the other hand, studies have shown that valve type and valve size had no effects on postoperative left ventricular mass (LVM). The objective of this report was to examine the relationships between patient characteristics or the prosthetic valve and postoperative LVM. METHODS: To evaluate the factors that influence postoperative LVM, we formulated the hypothesis that postoperative LVM is proportional to the sum total of pressure at the prosthetic valve orifice and inner surface area of the left ventricle in systole. We present a conceptually new index for postoperative LVM and compare the index with postoperative LVM. RESULTS: The results indicated a strong correlation between the new index and postoperative LVM six years after surgery (r(2) =0.67, p < 0.0001). As might be expected, LVM increased gradually as the value of the new index increased. CONCLUSIONS: The results of the present study indicate that postoperative left ventricular hypertrophy can be avoided by preventing postoperative hypertension in patients without left ventricular dilatation and an effective orifice area index is greater than 0.77 cm(2)/m(2).

A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds.

PURPOSE: This prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique. METHODS: The subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7. RESULTS: In the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001). CONCLUSIONS: The new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.

New method of thermal coronary angiography for intraoperative patency control in off-pump and on-pump coronary artery bypass grafting.

BACKGROUND: We evaluated the effectiveness of a new thermal coronary angiogram system using intraoperative imaging with an infrared camera for coronary artery bypass grafting. METHODS: The thermal coronary angiograms of 51 patients who underwent a total of 107 coronary artery bypass grafts were evaluated. Thermal coronary angiograms were obtained after completing distal anastomoses by the injection of cold saline solution into the vein grafts or free arterial grafts or by reperfusion with warmer blood in the internal thoracic artery grafts. Temperature differences of greater than 0.1 degrees C between the injectant and the epimyocardium resulted in high-contrast images. RESULTS: Thermal coronary angiograms were obtained from 107 coronary artery bypass grafts; 103 grafts were patent (96.3%), and 2 internal thoracic artery grafts were occluded. After reanastomoses, thermal coronary angiograms were again obtained, and all grafts appeared to be patent. Four grafts did not clearly show hemokinesis because of an intramyocardial segment or circumferential fat surrounding the artery. CONCLUSIONS: Thermal coronary angiograms cannot show hemokinesis clearly in cases with an intramyocardial arterial segment or in patients in whom the grafts are surrounded by fat. Therefore, thermal coronary angiograms are considered to play a valuable role in confirming the success or failure of myocardium revascularization because this diagnostic modality does not interfere with the surgical procedures, is noninvasive, and can be both quickly and easily performed.

Application of a new suture material called the U-Clip for composite and sequential grafting with off-pump coronary bypass surgery.

BACKGROUND: The U-Clip was found to facilitate the interrupted anastomosis of coronary artery bypass grafts (CABG). This device may be beneficial especially in multivessel off-pump CABG (OPCAB) using composite grafts or sequential anastomosis. The aim of this study was to evaluate our early clinical experience using the U-Clip in OPCAB cases. METHODS: This retrospective study included 118 patients who underwent off-pump CABG between 2001 and 2004. The mean age of the 91 men and 27 women was 69.5 +/- 8.0 years (range, 47-85). The U-Clip was adopted for sewing 73 proximal ends of the free graft to the side or end of the inflow conduit to prepare the composite graft. The U-Clip was also applied to 112 distal anastomoses, especially to the side-to-side anastomosis of the sequential graft. RESULTS: Hospital mortality rate was 0.8% (1/118). The early patency rate of distal anastomoses using the U-Clip was 95% (96/101). The early patency rate of proximal anastomoses using the U-Clip was 98.4% (62/63). Interim angiography was performed in 12 patients (range, 3.8-42 months; average, 16 months). In these 12 patients, a total of 8 proximal anastomoses of conduits using the U-Clip were all patent without stenosis. The patency rate of a total of 10 distal anastomoses in the 12 patients using the U-Clip was 100%. CONCLUSIONS: The U-Clip-interrupted anastomosis enables a safe, definite, and rapid end-to-end or end-to-side connection of arterial grafts. We therefore consider the U-Clip to be a useful suture material especially for multivessel OPCAB using multiple arterial grafts.

Aortic valve replacement after esophagectomy with substernal gastric tube reconstruction.

A 67-year-old woman with a history of esophagectomy with substernal gastric tube (GT) reconstruction and left lower lobectomy required aortic valve replacement (AVR) for aortic valve regurgitation and stenosis. Through a median sternotomy (MS) with cardiopulmonary bypass (CPB), we performed AVR without injury to the GT. Careful peeling of the GT and detailed information of the operative field by multidetector-row computed tomography (MDCT) scan enabled us to carry out the operation safely in the usual operative view.

Dysfunction of an ATS valve in the aortic position: the first reported case caused by pannus formation.

A 64-year-old woman underwent aortic valve replacement with a 21-mm Advancing The Standard (ATS) open-pivot mechanical heart valve for bicuspid aortic valve stenosis. In addition to the appearance of a new cardiac murmur, echocardiography performed 3 years after surgery showed a high pressure gradient across the ATS valve and a reduction in the valve orifice area. Cineradiography of the valve revealed restricted leaflet opening. Subsequent multidetector-row computed tomography clearly demonstrated pannus overgrowth on the inflow aspect of the ATS valve. During a repeat operation, subvalvular overgrown pannus was confirmed and the ATS valve was replaced with a bioprosthetic valve. This is the first reported case of prosthetic valve dysfunction resulting from pannus formation in a patient with an ATS valve in the aortic position.