Endovascular Aortic Repair for a Symptomatic Mycotic Aneurysm With Listeria monocytogenes: A Case Report.

PURPOSE: To report a case of successful endovascular aortic repair for a symptomatic mycotic abdominal aortic aneurysm infected with Listeria monocytogenes. CASE REPORT: We report the case of an 88-year-old woman who presented with acute abdominal pain and vomiting. Approximately a year prior to her presentation, the patient was diagnosed with a mycotic abdominal aortic aneurysm with Listeria monocytogenes and was treated conservatively for more than 2 months at another hospital. At our hospital, contrast-enhanced computed tomography revealed an abdominal aortic aneurysm and an aneurysm of the left internal iliac artery. Endovascular aortic repair was performed successfully. At 16 months after the surgery, the patient remained asymptomatic on long-term antibiotics, and there was no enlargement of the aneurysm. CONCLUSION: Endovascular aortic repair and lifelong antibiotics may be an alternative therapy for mycotic abdominal aortic aneurysms. However, the risk of recurrent infection is high and warrants long-term follow-up.

Surgical Management of Perigraft Seroma by Graft Wrapping with Local Hemostatic Agents: A Case Report.

A 76-year-old female developed progressive local groin bulging. She received regular hemodialysis using a left-thigh polytetrafluoroethylene arteriovenous graft in the loop configuration. Lower extremity enhanced computed tomography showed a large low-density area around the graft 18 months after its creation, and perigraft seroma (PS) was suspected. The patient underwent PS excision followed by graft wrapping with two local hemostatic agents, oxidized regenerated cellulose, and a fibrin sealant. Local PS recurrence was not detected four months after surgery. We herein describe a surgical case of refractory PS successfully treated by graft wrapping using two local hemostatic agents.

Acquired left ventricular-right atrial communication after mitral valve replacement and tricuspid annuloplasty.

A 77-year-old woman underwent mitral valve replacement and tricuspid annuloplasty for severe mitral stenosis and tricuspid regurgitation with pulmonary hypertension. Two months later, the patient was readmitted because of marked edema. A new harsh pansystolic murmur was auscultated, and echocardiography revealed a jet from the left ventricle to the right atrium but no paravalvular leakage was detected at the mitral valve position. At operation, an 6 mm defect adjacent to the tricuspid annulus in the interatrial septum and detachment of the anterior edge of the tricuspid ring were detected. The defect was closed using a pericardial patch. An inadequate stitch at the anteroseptal commissure in the previous operation led to left ventricular-right atrial communication.

Aortic Root Replacement via Lower Hemisternotomy After an Esophageal Operation.

A 68-year-old man with a history of esophageal resection and reconstruction by gastric tube in substernal fashion required aortic root replacement for annuloaortic ectasia and severe aortic regurgitation. The gastric tube attached closely at the manubrium of the sternum and around the xiphoid process, but it positioned leftward slightly at the body of the sternum. At the operation of the aortic root replacement, we decided the lower hemisternotomy approach to avoid injury of the gastric tube. The lower hemisternotomy to access the aortic root provides a useful alternative approach in some cases with substernal reconstruction after surgery of esophageal cancer.

Peripheral Arterial Disease with Small Aorta Syndrome: A Case Report.

We report a case of a 79-year-old woman who experienced difficulty in walking. Contrast-enhanced computed tomography revealed severe stenosis and calcification of the infrarenal aorta. The minimum diameter of the infrarenal aorta was 8 mm and that of the common femoral artery was 4 mm. Other vessels with abnormalities were the hypoplastic left subclavian artery and the left-sided inferior vena cava. The patient was treated with right axillobifemoral bypass. In patients with small aorta syndrome, the graft patency rate is low, and long-term follow-up is important.

Absent right common carotid artery associated with aberrant right subclavian artery.

Rarely, the external and internal carotid arteries arise separately from the brachiocephalic trunk and right subclavian artery (SA) or the aortic arch and reflect the absence of a common carotid artery (CCA). We report a 45-year-old man with absent right CCA associated with aberrant right SA, an extremely rare combination, diagnosed by computed tomography (CT) angiography during follow-up for postoperative aortic dissection. Retrospective careful observation of preoperative postcontrast CT revealed the absent right CCA. Previously reported arch variations associated with absent CCA include cervical aortic arch, double aortic arch, and right aortic arch.

[Re-operation for Saccular Aneurysm after Ascending Aortic Replacement with Homograft;Report of a Case].

A 62-years-old female had undergone ascending aortic replacement with homograft for graft infection and mediastinitis after initial replacement of ascending aorta due to acute type A dissection. Ten years after homograft replacement, follow up computed tomography showed acute growing saccular aneurysm of the homograft without infectious symptoms. We urgently performed Bentall procedure and hemiarch replacement successfully. Pathological diagnosis was true aneurysm of the homograft. She was discharged from hospital without any complication and has been quite uneventful 7 years after surgery. True aneurysm of the homograft is very rare and our case is the 1st report of successful reoperation.

Diagnostic features of cardiac cavernous hemangioma in the right ventricle on magnetic resonance imaging.

Cardiac tumors are rare; however, with recent advances in imaging techniques, they are being diagnosed more frequently with cardiac magnetic resonance (CMR) imaging. We report a case of a cardiac cavernous hemangioma in the right ventricle. This case was diagnosed with CMR imaging based on the characteristic features of peripheral nodular contrast enhancement and progressive centripetal fill-in. CMR imaging also provided useful preoperative anatomical information, showing the relationships among the tumor, tricuspid valve, and right ventricular anterior wall.

Preserved autoregulation of coronary flow after off-pump coronary artery bypass grafting: retrospective assessment of intraoperative transit time flowmetry with and without intra-aortic balloon counterpulsation.

BACKGROUND: Intra-aortic balloon pumping (IABP) markedly increases graft flow after coronary artery bypass grafting (CABG) with cardiopulmonary bypass. We sought to delineate the effects of IABP on graft flow after off-pump CABG (OPCAB). METHODS: The clinical records of 32 patients (25 male, 7 female; mean age: 70 ± 9 years) who underwent OPCAB with IABP between January 2011 and May 2015 were retrospectively reviewed. Thirteen patients (41%) had a history of myocardial infarction, and 13 patients (41%) had a history of percutaneous coronary intervention. In total, there were 76 bypass grafts with 102 distal anastomoses. These included 50 in situ or pedicled grafts and 26 aortocoronary grafts. After completion of the anastomoses, the heart was positioned normally, and graft flow with IABP was measured using transit-time flowmetry under stable circulation. Then, IABP was turned off for 30 s to a few minutes, until graft flow was constant, for measurement of flow off IABP. RESULTS: The angiographic patency rate was 100% (47/47). Overall, graft flow was 55 ± 36 ml/min on IABP and 53 ± 36 ml/min off IABP (p = 0.37). The pulsatility index was 4.1 ± 2.1 on IABP and 2.7 ± 1.5 off IABP (p < 0.001). There was no significant difference in graft flow between on and off IABP for aortocoronary bypass or in situ grafts. Graft flow was 57 ± 36 ml/min on IABP and 55 ± 37 ml/min off IABP (p = 0.41) in in situ grafts and 52 ± 34 ml/min on IABP and 49 ± 35 off IABP (p = 0.41) in aortocoronary grafts. Graft flow on IABP was more than 5 ml/min greater in 28 (37%) bypass grafts, and more than 5 ml/min lower in 20 (26%) bypass grafts. CONCLUSION: In contrast to previous reports for conventional CABG, graft flow after OPCAB was not necessarily increased by IABP, regardless of elevated diastolic arterial pressure. It is suggested that preserved autoregulation of coronary flow contributes to a lower impact on the heart and early functional recovery, and consequently, greater perioperative safety of OPCAB.

Comparison of early haemodynamics of 19-mm aortic valve bioprostheses in patients with a small aortic annulus.

OBJECTIVES: A potential problem in aortic valve replacement (AVR) for patients with a small aortic annulus is prosthesis-patient mismatch (PPM). Although larger size prostheses have been well studied, the haemodynamics of 19-mm bioprostheses has been reported in only a small number of patients. The Trifecta valve is a novel bioprosthesis and its unique design is conceived to increase effective orifice area (EOA) and prevent PPM. This study aims at comparing the early haemodynamics of the new Trifecta valve with that of other conventional 19-mm valves. METHODS: We retrospectively evaluated 128 consecutive patients who underwent AVR with 19-mm bioprosthesis (39 Trifecta valve, 67 Magna Ease valve and 22 Mosaic Ultra valve) at Saitama International Medical Center between April 2012 and December 2014. Haemodynamics was evaluated by transthoracic echocardiography at 1 month after discharge and at 1-year follow-up. RESULTS: The average body surface area of all patients was 1.37 m(2). There was no difference in postoperative clinical outcomes between the three groups. Among the three groups, the mean pressure gradient (MPG) was the smallest (10.6 ± 4.3 mmHg, P < 0.001) and the EOA was the largest (1.63 ± 0.36 cm(2), P < 0.001) in the Trifecta group at 1 month after discharge. In the Trifecta group, PPM was not observed (P < 0.001), the MPG was the smallest (12.8 ± 3.6 mmHg, P < 0.001) and the EOA was the largest (1.50 ± 0.30 cm(2), P < 0.001) at the 1-year follow-up. CONCLUSIONS: The new 19-mm Trifecta valve showed favourable early haemodynamics compared with the conventional valves and may be useful for preventing PPM in patients with a small aortic annulus.

Myectomy as an alternative solution for systolic anterior motion in a patient who underwent mitral valve repair.

Systolic anterior motion (SAM) of the mitral apparatus is a relatively frequent complication of mitral valve repair. When significant SAM persists despite intraoperative medical therapies, a second repair is generally required. We describe a rare case of SAM due to a hypertrophic septum in a patient who underwent mitral valve repair, with no preoperative obstruction of the left ventricular outflow tract. The present case of SAM was successfully treated only with transaortic septal myectomy. Therefore, myectomy might be considered as an alternative solution for SAM that is suspected to be caused by a hypertrophic septum after mitral valve repair.

Impacts of intraoperative flow on graft patency of sequential and individual saphenous vein grafts.

OBJECTIVE: We sought to delineate the predictor of saphenous vein graft (SVG) failure and to evaluate the impact of sequential grafting of SVG on graft flow as the significant predictor of patency. METHODS: Angiograms and clinical records of 439 patients who underwent coronary artery bypass grafting with aortocoronary SVG were reviewed. Of these, 708 distal anastomoses were created by 480 SVGs. Of 349 patients who underwent isolated coronary artery bypass grafting, operation was performed with an off-pump technique in 347 patients (99%). For 90 patients, a combined procedure on cardiopulmonary bypass was performed. A postoperative angiography was performed in 230 SVGs for clinical reasons. Insufficient flow (IF) was defined as a graft flow of 20 mL/min or less, measured by transit-time Doppler flowmetry during operation. RESULTS: In 480 SVGs, 44 (9.2%) presented IF, and 24 SVGs presented partial or total occlusion. Six of the nine failed individual SVG had IF, whereas none of the failed sequential SVG was associated with IF. Univariate and multivariate logistic regression analyses demonstrated that IF (P = 0.002; odds ratio, 6.63) and sequential grafting (P = 0.004; odds ratio, 2.51) were significantly correlated with a failure of the SVG. The patency rate of sequential SVG to the most distal target was 78/93 (83.9%), which was significantly lower than 9/139 (93.5%) of the individual SVG (P = 0.02) and 7/113 (93.8%) of the sequential SVG to proximal targets (P = 0.02). CONCLUSIONS: When both targets seem to have sufficient demand, avoidance of sequential grafting would be reasonable. Moreover, the important target should be grafted by individual grafting or sequential proximal anastomosis.

[Surgery for Ventricular Tachycardia Arising from Left Ventricular Aneurysm in a Patient with Dilated Cardiomyopathy；Report of a Case].

A left ventricular aneurysm (LVA) generally results from myocardial infarction, but rarely LVA can be associated with dilated cardiomyopathy (DCM). We herein report a surgical case of malignant ventricular tachycardia (VT) in a patient with LVA associated with DCM. A 57-year-old woman was diagnosed with DCM and LVA when she 1st presented with sustained VT. She had anti-arrhythmic medical therapy and implantable cardiac defibrillator. Subsequently, she presented with recurrent monomorophic VT arising from the LVA. Because anti-arrhythmic medical therapy and endocardial ablation were not effective, the patient was performed left ventricular aneurysmectomy and encircling endocardial cryoablation and could achive good arrhythmic control and clinical outcome.

Emergent surgical repair of left ventricular rupture after blunt chest trauma.

A 63-year-old man presented with sudden cardiac shock due to cardiac rupture after a blunt chest trauma. We emergently repaired 2 rupture sites with the sandwich technique. This technique maintained the ventricular geometry, and minimized impairment of cardiac function.

Evaluation of perivalvular infectious ventricular pseudoaneurysm by ECG-gated cardiac computed tomography: 2 case reports.

Left ventricular (LV) pseudoaneurysm is a serious complication of periannular extension of infective endocarditis (IE). Because pseudoaneurysm carries a high risk of rupture, its detection and evaluation are crucial for patient management and surgical planning. We report 2 cases with LV pseudoaneurysms, one near the aortic valve and the other near the mitral valve, which were caused by IE and treated successfully. In both cases, cardiac multidetector-row computed tomography enabled detection of the LV pseudoaneurysm and a detailed demonstration of its anatomic relationship with surrounding structures, which helped guide surgical planning.

Comparative molecular and microbiological diagnosis of 19 infective endocarditis cases in which causative microbes were identified by PCR-based DNA sequencing from the excised heart valves.

Infective endocarditis (IE) is traditionally diagnosed by microbiological analysis of blood cultures, following which therapeutic antibiotics are chosen based on antimicrobial sensitivity tests. However, such conventional techniques do not always lead to an accurate etiological diagnosis. Recently, PCR analysis of the 16S rRNA gene has been employed to identify organisms isolated from excised heart valves. In this study, we analyzed 19 valve samples from patients with confirmed IE, as identified by Duke's criteria. Using broad-range PCR amplification, followed by direct gene sequencing, pathological agents were identified in all samples. Although blood cultures yielded negative results in 4 cases, PCR analysis of valve samples showed positive identification of causative organisms. In 3 cases, there was a difference between blood culture and PCR in identification of pathological agents, which are likely to be misidentified by the conventional method based on the phenotypic database. Postoperative antibiotics were chosen considering the severity of lesions and the results of PCR, Gram staining, and valve cultures. All patients were cured without relapse. The broad-range PCR method was therefore beneficial for the management of IE because it enabled us to identify pathogens directly from the site of infection, even organisms that were difficult to culture or likely to be misidentified by the conventional culture method. Identification of the agents provided precise knowledge of the microbiological spectrum involved in the cases of IE.

[New surgical approach for acute type A aortic dissection; combining classic surgery with descending stent grafting].

The outcome of surgical repair of acute type A dissection has substantially improved, but patients with residual dissection in the descending aorta are facing a risk of late complications such as aneurysm formation and rupture, and often require redo surgery. To minimize late complications, the combined approach with hemi-arch replacement and simultaneous descending stent grafting (SG) was applied and compared with conventional surgery. Between April 2007 and April 2010, 70 consecutive patients with acute type A dissection underwent operation, and 8 with DeBakey type II and 9 undergoing total-arch replacement were excluded from the study. 38 patients (71.7%) underwent combined surgery with SG and 15 (28.3%) underwent conventional surgery. Computed tomography (CT) was performed during the follow-up. Patency, width of the false lumen and the maximal diameter of the descending aorta were compared between these 2 groups. In early CT, the thoracic true lumen was wider than the false lumen in 28 patients (80%) in the SG group and 7 (50%) in the conventional group (p = 0.04). In mid-term CT, dilatation of the thoracic aorta occurred in 5 patients (16.1%) in the SG group and 5 (45.5%) in the conventional group (p < 0.05). This approach is technically feasible and offers the chance of thrombosis and reduction of the distal false lumen.

Ascending to descending aorta bypass for middle aortic syndrome.

Though stenoses of the descending aorta and its branches are seen with congenital anomalies or systemic inflammation, occlusion of the descending aorta is extremely rare. A patient with an occluded hypoplastic descending thoracic aorta required re-operation because of graft failure between the descending thoracic aorta and the infrarenal abdominal aorta. The etiology of the aortic occlusion in this case is unknown, but inflammation, such as Takayasu disease, is speculated.