First jejunal artery, an alternative graft for right hepatic artery reconstruction.

Common bile duct cancer invading right hepatic artery is sometimes diagnosed intraoperatively. Excision and safe reconstruction of the artery with suitable graft is essential. Arterial reconstruction with autologous saphenous vein graft is the preferred method practiced routinely. However the right hepatic artery reconstruction has also been carried out with several other vessels like gastroduodenal artery, right gastroepiploic artery or the splenic artery. We report a case of 63-year-old man presenting with history of progressive jaundice, pruritus and impaired appetite. Following various imaging modalities including computed tomography, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, intraductal ultrasound extrahepatic bile duct cancer was diagnosed; however, none of those detected vessel invasion. Intraoperatively, right hepatic artery invasion was revealed. Right hepatic artery was resected and reconstructed with a graft harvested from the first jejunal artery (JA). Postoperative outcome was satisfactory with a long-term graft patency. First JA can be a reliable graft option for right hepatic artery reconstruction.

Tricuspid regurgitation after mitral valve repair for degenerative mitral regurgitation.

PURPOSE: We examined changes of TR (tricuspid regurgitation) after mitral valve repair for degenerative mitral regurgitation (MR) and investigated their contributing parameters. METHODS: We divided 205 patients undergoing mitral valve repair for degenerative MR into 3 groups: up-grade (n = 65), down-grade (n = 29), and no-change (n = 111) of TR during postoperative follow-up. Preoperative, immediate postoperative, and mid-term postoperative parameters included MR grade, right ventricular (RV) pressure, RV Tei index, left ventricular Tei index, and presence of atrial fibrillation. RESULTS: Preoperative incidence of atrial fibrillation in the down-grade group was lower (7%) than those in the other groups (37% and 34%). In the immediate postoperative stage, the TR grade of the up-grade group was significantly lower (p <0.001) and RV Tei index of the downgrade group was significantly lower (p = 0.049). In mid-term postoperative stage, the TR grade (p <0.001) and RV Tei index (p = 0.034) of the down-grade group were significantly lower, and the MR up-grade in the TR up-grade group was significantly frequent (p = 0.008). CONCLUSIONS: TR became deteriorated even after the operation in about 30% and remained unchanged in about 50%. The RV Tei index can be a reliable parameter to predict postoperative improvement of TR. The postoperative MR up-grade was related to the TR up-grade.

Should mitral annuloplasty be performed for patients with mild ischemic mitral regurgitation?

PURPOSE: We investigated whether mitral annuloplasty (MAP) should be performed for mild ischemic mitral regurgitation (IMR). METHODS: We selected 57 patients with preoperatively mild IMR. Twenty-eight patients who previously had moderate MR or more, underwent MAP (group 1) while 29 patients with persistent mild MR, did not (group 2). We reviewed MR changes and outcomes of these patients. We also investigated other IMR patients with preoperatively moderate or more MR as reference data (group 3). RESULTS: In group 1, MR was none or trace in 25 patients immediately after operation, however, eleven out of these patients (44%) showed postoperative MR up-grade. The trends of MR changes in group 1 were similar to those of patients in group 3. In group 2, MR was graded mild in 79% of patients in mid-term postoperative stage although 28% of patients were up-graded or down-graded during postoperative follow-up. CONCLUSION: MAP is not necessary for patients with persistently mild IMR. Patients with preoperatively mild IMR with episodes of MR exacerbation had better be treated similarly as those with moderate or more IMR and undergo MAP.

Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion.

OBJECTIVE: Diastolic subvalvular mitral leaflet tethering by left ventricular remodeling that restricts leaflet opening in the presence of annular size reduction by surgery for ischemic mitral regurgitation potentially causes functional mitral stenosis in the absence of organic leaflet lesions. Exercise, known to worsen systolic tethering and ischemic mitral regurgitation, might also dynamically exacerbate such mitral stenosis by increasing tethering. This study evaluates the mechanism and response of such mitral stenosis to exercise. METHODS: We measured the diastolic mitral valve area, annular area, and peak and mean transmitral pressure gradient by echocardiography in 20 healthy individuals and 31 patients who underwent surgical annuloplasty for ischemic mitral regurgitation. RESULTS: Although the mitral valve area and annular area did not significantly differ in healthy individuals (4.7 +/- 0.6 cm(2) vs 5.2 +/- 0.6 cm(2), not significant), mitral valve area was significantly smaller than the annular area in patients after annuloplasty (1.6 +/- 0.2 cm(2) vs 3.3 +/- 0.5 cm(2), P < .01). The mitral valve area was less than 1.5 cm(2) only after the surgery (P < .01) and was significantly correlated with restricted leaflet opening (r(2) = 0.74, P < .001), left ventricular dilatation (r(2) = 0.17, P < .05), and New York Heart Association functional class (P < .05). Exercise stress echocardiography of 12 patients demonstrated dynamic worsening in functional mitral stenosis (mitral valve area: 2.0 +/- 0.5 cm(2) to 1.4 +/- 0.2 cm(2), P < .01; mean pressure gradient: 1.5 +/- 0.9 mm Hg to 6.0 +/- 2.2 mm Hg, P < .01). CONCLUSIONS: Persistent subvalvular leaflet tethering in the presence of annular size reduction by surgery in ischemic mitral regurgitation frequently causes functional mitral stenosis at the leaflet tip level, which is related to heart failure symptoms and can be dynamic with significant exercise-induced worsening.

Left ventricular reconstruction with or without mitral annuloplasty.

OBJECTIVES: The aim of this study was to review characteristics of patients undergoing left ventricular reconstruction (LVR) with or without mitral annuloplasty (MAP) for postinfarction ventricular remodeling. PATIENTS AND METHODS: Forty-seven patients were divided into two groups: LVR (LVR group, n = 22) and LVR with MAP (LVRM group, n = 25). Echocardiographic parameters including left ventricular (LV) dimensions, LV end-diastolic and end-systolic volume indexes, and LV ejection fraction (LVEF) at immediate and midterm postoperative stages were evaluated. The perioperative contributing factors to all deaths and death from congestive heart failure (CHF) were analyzed in all 47 patients. RESULTS: Patients in the LVRM group had greater preoperative LV dimension and volume, and significantly lower LVEF, with notably frequent use of intra-aortic balloon pumping. All postoperative deaths occurred within 1 year from surgery. The LV end-diastolic volume > 110 ml/m2 and creatinine > 1.2 mg/dl were significant preoperative contributing factors to all deaths, and the latter was to CHF deaths. CONCLUSIONS: The coexistence of ischemic mitral regurgitation with LV dilatation required more aggressive surgical approaches for the patients with more impaired LV function. More intensive postoperative management is required for patients with enlarged hearts and renal dysfunctions.

Abnormal Tei index predicts poor left ventricular mass regression and survival after AVR in aortic stenosis patients.

BACKGROUND: A Tei index is known to reflect overall cardiac performance including systolic and diastolic function in a variety of heart disease. We investigated the relationship between preoperative Tei index and postoperative left ventricular (LV) mass regression and survival after aortic valve replacement (AVR) for aortic valve stenosis (AS). METHODS: One hundred fifty-four patients with AS were classified into a group with abnormal (Abn) LV function (n=47, 0.45 < or = Tei index) and a group with normal (Nor) LV function (n=107, Tei index < 0.45). The pre- and postoperative echocardiographic variables including LV dimension, LV wall thickness, and LV mass regression as well as 6-year survival were compared between the two groups. RESULTS: There was a significant difference in both absolute and relative LV mass index (LVMI) regression (P=0.004 and 0.0007). Multiple linear regression analysis revealed that the preoperative LVMI, Tei index, and follow-up period were independent predictors of LVMI regression after AVR. Thirteen patients died (valve-related death in 5). Although the overall survival rate in the Nor-LV group (92.8%) was significantly better than that in the Abn-LV group (71.6%), there was no significant difference in survival free from valve-related death. CONCLUSIONS: Preoperative Tei index can be one of the significant predictors of LVMI regression and overall survival after AVR.

Protective effect of sivelestat sodium hydrate (ONO-5046) on ischemic spinal cord injury.

Prevention of paraplegia remains an important issue in repair of descending thoracic and thoracoabdominal aneurysms. Therefore, we investigated the protective effect of sivelestat sodium hydrate (ONO-5046) on ischemia-induced spinal cord damage in a rabbit model. Twenty New Zealand white rabbits were divided into two equal groups; ONO-5046 (1.6 mg/kg)+isotonic NaCl (30 ml) was administered selectively to the spinal cord via the lumbar arteries for the first 3 min during 30 min of infra-renal aorta clamping in the experimental group (group E), whereas NaCl was given alone in the control group (group C). Motor function of the lower limbs was assessed two days later by Tarlov criteria. The number of intact motor neurons in the anterior segment of the cord (L5 level) was counted after hematoxylin-eosin staining and the number of apoptotic motor neurons after TUNEL staining. Motor function of the lower limbs in group E was significantly better (P=0.003) than that in group C. The number of intact motor neurons was greater and of apoptotic motor neurons was less in group E than C. Selective infusion of sivelestat sodium hydrate directly into the spinal cord via the lumbar arteries significantly attenuated functional and morphological ischemia-induced spinal cord injury.

Impact of subvalvular procedure for ischemic mitral regurgitation on leaflet configuration, mobility, and recurrence.

BACKGROUND: Procedures on the subvalvular apparatus are an etiology-based treatment for ischemic mitral regurgitation (IMR). METHODS AND RESULTS: Fifty-nine patients with IMR were divided into 3 groups: mitral annuloplasty (MAP) (M group, n=27), MAP+left ventricular reconstruction (LVR) (LV group, n=18), and MAP+LVR+subvalvular procedure (S group, n=14). Tenting height and area, angle between the annular line and the line connecting leaflet base to the bending- or tip-point of either the anterior or posterior leaflet, and leaflet mobility were measured echocardiographically preoperatively and at immediate- and mid-term postoperative follow-up. The angles at the bending-point of the anterior leaflet in mid-systole remained greater than those at its tip-point in the M and LV groups, but became significantly smaller postoperatively only in the S group (p<0.05). Postoperative leaflet mobility at the bending-point in the S group became significantly greater than in the other groups (p<0.01). The grade of MR, after significant reduction by the procedure, increased again in the M and LV groups, but remained almost unchanged in the S group. CONCLUSION: Subvalvular procedures improved the configuration and mobility of the anterior leaflet, and can be expected to reduce the recurrence of IMR.

Radical repair of cor triatriatum with partially unroofed coronary sinus and persistent left superior vena cava 35 years after operation for tetralogy of Fallot.

We report a rare case of simultaneous repair for Cor triatriatum (CT), partially unroofed coronary sinus (CS) with persistent left superior vena cava (PLSVC), moderately severe tricuspid regurgitation, and atrial flutter 35 years after radical operation for tetralogy of Fallot (TOF). A 40-year-old woman underwent patch closure of atrial septal defect as to drain blood from left SVC to right atrium (RA), excision of diaphragm in left atrium (LA), tricuspid annuloplasty, and cryoablation. Postoperative course was uneventful with successful anatomical correction.

Intervalvular fibrosa pseudoaneurysm with projectile shunt flow to left atrium.

We report a case of intervalvular fibrosa pseudoaneurysm, causing massive shunt flow from the left ventricle below the left coronary cusp to the left atrium above the anterior mitral annulus, which was clearly demonstrated on preoperative three-dimensional transesophageal echocardiography. Superior extension of the right-sided left atriotomy toward the pseudoaneurysm, combined with transection of aorta and main pulmonary artery, provided its sufficient exposure. Its opening to the left ventricle was closed with a patch, leaving no residual shunt flow.

Preoperative advanced left ventricular remodeling predisposes to recurrence of ischemic mitral regurgitation with less reverse remodeling.

BACKGROUND AND AIM OF THE STUDY: The recurrence of ischemic mitral regurgitation (IMR) after mitral annuloplasty is a major determinant of patient survival. The study aim was to investigate, retrospectively, the characteristics of patients with postoperative recurrence of IMR. METHODS: Twenty patients who had no regurgitation immediately after mitral annuloplasty, were allocated to either recurrence (n = 8) or non-recurrence (n = 12) groups. Recurrence was defined as any interval upgrade of regurgitation. The patients' preoperative profiles and parameters of preoperative, immediate postoperative and intermediate postoperative echocardiography were compared. RESULTS: Patients with recurrence were more frequently dyspneic and had a significantly higher cardiothoracic ratio (p = 0.041) on radiologic examination. The preoperative left ventricular end-diastolic and end-systolic dimensions (p = 0.018 and 0.021), and left ventricular end-diastolic and end-systolic volumes (p = 0.038 and 0.041), and left ventricular wall motion score (p = 0.0002) were significantly greater in the recurrence group. These differences in left ventricular volume persisted at the immediate and intermediate postoperative stages. Reverse remodeling occurred at a ca. 50% lower rate in the recurrence group, and was associated with significantly smaller preoperative left ventricular dimension and volume. At intermediate follow up, the left ventricular ejection fraction was improved and significantly greater in the non-recurrence group (p = 0.024), but remained unchanged in the recurrence group. CONCLUSION: Advanced left ventricular remodeling and dilatation before surgery predispose to a recurrence of mitral regurgitation and a lesser incidence of reverse remodeling. Mitral annuloplasty alone may have a limited role in preventing the recurrence of regurgitation in the case of advanced IMR, without functional recovery.

Papillary muscle elevation: an alternative subvalvular procedure for selective relocation of displaced posterior papillary muscle in posteroinferior infarction.

Several subvalvular procedures have been developed for relocating one or both displaced papillary muscles. We describe an original procedure--papillary muscle elevation--in which we relocated the posterior papillary muscle selectively, through a small inferior ventriculotomy, and reduced the coaptation depth from 5 mm to zero. Our procedure can be considered for cases of posteroinferior infarction, which is a frequent cause of ischemic mitral regurgitation.

Subvalvular procedure for functional mitral regurgitation in a patient with dilated-phase hypertrophic cardiomyopathy.

Surgical correction of the subvalvular apparatus to reduce tethering, along with mitral annuloplasty, has recently been highlighted in the treatment of functional mitral regurgitation. However, because of anatomical differences in the subvalvular apparatus between cases of progressive cardiomyopathy, a uniform procedure to reduce tethering has not been established. We report a case-specific reconstructive method consisting of procedures mainly on papillary muscles for a rare case of dilated-phase hypertrophic cardiomyopathy with moderately severe mitral regurgitation.

Mid-term changes of left ventricular geometry and function after Dor, SAVE, and Overlapping procedures.

BACKGROUND: The aim of this study was to investigate the mid-term changes of left ventricular (LV) geometry and function after Dor, septal anterior ventricular exclusion (SAVE), and Overlapping ventricular remodeling procedures. METHODS: Forty-three patients who underwent LV reconstruction for end-stage ischemic heart disease, were divided into three groups, undergoing Dor (n=15), SAVE (n=12), and Overlapping procedures (n=16). Coronary artery bypass grafting and mitral annuloplasty were performed concomitantly when indicated. Left ventricular diastolic and systolic dimensions (LVDd and LVDs), LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI), LV ejection fraction (LVEF), deceleration time (DcT), sphericity index (SI), and grade of mitral regurgitation were measured on preoperative and postoperative (immediately and at intermediate-term) echocardiography. RESULTS: In the Dor group, the LVEDVI and LVESVI were significantly reduced immediately after the operation, and increased again at intermediate follow-up. The SI was significantly increased immediately after the operation and increased thereafter in a linear fashion. In the SAVE group, the DcT was significantly reduced immediately after the operation and was not improved in the later stage. In the Overlapping group, the LVEDVI and LVESVI were significantly reduced, and remained as such at intermediate follow-up. The SI was not increased and remained almost unchanged after the operation. CONCLUSION: Progression in LV sphericity after the Dor procedure and persistent reduction of the DcT after the SAVE procedure seem to be procedure-related problems. The Overlapping procedure provided significant LV volume reduction, maintaining the most elliptical LV shape with acceptable early and late mortality.

Intraoperative infusion of epoprostenol sodium for patients with heparin-induced thrombocytopenia undergoing cardiac surgery.

Prevention of catastrophic thromboembolic complications during surgery in patients with heparin-induced thrombocytopenia (HIT) remains a challenging problem during cardiac surgery. We infused an increasing dose of epoprostenol sodium, which is one of three anti-HIT regimens available in Japan, ahead of administration of heparin and performed a mitral valve operation for a patient with type II HIT. The absence of thromboembolic events and platelet consumption during cardiopulmonary bypass, together with considerable reduction of platelet adhesion to the fibers of the membrane oxygenator, support the efficacy and safety of our strategy.

Mechanism of recurrent/persistent ischemic/functional mitral regurgitation in the chronic phase after surgical annuloplasty: importance of augmented posterior leaflet tethering.

BACKGROUND: Surgical annuloplasty can potentially hoist the posterior annulus anteriorly, exaggerate posterior leaflet (PML) tethering, and lead to recurrent ischemic/functional mitral regurgitation (MR). Characteristics of leaflet configurations in late postoperative MR were investigated. METHODS AND RESULTS: In 30 patients with surgical annuloplasty for ischemic MR and 20 controls, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, posterior and apical displacement of the coaptation and the MR grade were measured by echocardiography before, early after, and late after surgery. Early after surgery, grade of MR and AML tethering generally decreased (P<0.01), whereas PML tethering significantly worsened (P<0.01). Nine of the 30 patients showed recurrent/persistent MR late after surgery. Compared with patients without late MR, those with the MR showed similar reduction in the annular area, significant re-increase in posterior displacement of the coaptation, and progressive worsening in PML tethering (P<0.05) late after surgery in comparison to the early phase. Both preoperative MR and late postoperative MR were significantly correlated with all tethering variables in univariate analysis. Although apical displacement of the coaptation was the primary determinant of preoperative MR (r2=0.60, P<0.0001), increased PML tethering was the primary determinant of late MR (r2=0.75, P<0.0001). CONCLUSIONS: Whereas both leaflets tethering is related to preoperative ischemic MR, both leaflets tethering but with predominant contribution from augmented and progressive PML tethering is related to recurrent/persistent ischemic/functional MR late after surgical annuloplasty.

New surgical approach to reduce tethering in ischemic mitral regurgitation by relocation of separate heads of the posterior papillary muscle.

The surgical treatment of chronic ischemic mitral regurgitation remains a challenging issue. Several procedures have been developed to correct displacement of the papillary-ventricular complex and to reduce tethering-induced regurgitation. We report a geometric approach to relocate the laterally displaced posterior papillary muscle towards the mitral annulus. This procedure is believed to be technically easy and useful, especially in cases in which the displaced posterior papillary muscle contributes to tethering-induced regurgitation.

Vasodilator resistant lethal spasm after uncomplicated off-pump coronary surgery.

We report a case of lethal spasm of non-grafted coronary arteries after an uncomplicated off-pump coronary artery bypass grafting in a patient with no predisposing factors other than smoking. Transcatheter intraluminal injection of several vasodilators failed to relieve the spasm. The patient remained in profound cardiogenic shock due to broad acute myocardial infarction and died of multiple organ failure.

Emergent mitral valvuloplasty with an autologous pericardial patch in an octogenarian with active infective endocarditis.

An 83-year-old woman with suppurative spondylitis was referred to our hospital due to active infective endocarditis with an expanding mobile vegetation and a high echoic mass on the posterior mitral leaflet. During the operation, the high echoic mass was found to be a chronically organized abscess, which was located at the base of the vegetation on the posterior leaflet and extended toward the annulus. The patient underwent a successfully emergent resection of the vegetation and mass, and valvuloplasty using an autologous pericardial patch with an excellent outcome.

Characteristic changes in cerebral perfusion during on-pump and off-pump coronary artery surgery.

OBJECTIVE: We investigated the cerebral perfusion status during on-pump or off-pump coronary artery bypass grafting (CABG). METHODS: We monitored somatosensory evoked potential (SEP) and regional cerebral oxygen saturation (rSO2) as parameters of cerebral perfusion in an on-pump group (n=10) and an off-pump group (n=16). The percent changes from control values were calculated before, during, and after aortic clamping, and after weaning from cardiopulmonary bypass, in the on-pump group. In the off-pump group, these were calculated before, during, and after heart displacement for distal anastomosis. RESULTS: In the on-pump group, the amplitudes of the SEP were significantly enhanced during and after aortic cross-clamping and were associated with a significant decrease in rSO2. Latency was prolonged immediately after aortic cross-clamping, but was shortened afterwards. There was little change in these parameters throughout the operation, in the off-pump group. CONCLUSIONS: Cerebral perfusion remains stable during off-pump CABG. The etiology of a simultaneous increase in SEP amplitude and decrease in rSO2 during the rewarming period in the on-pump group requires further investigation.