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.

Engineering of functional cardiac tubes by stepwise transplantation of cardiac cell sheets onto intestinal mesentery.

Implantable organ-like grafts made using tissue engineering techniques could potentially be used as circulatory assist devices in people with heart failure. The aims of this study were to engineer implantable, thick cardiac tubes by the stepwise transplantation of cardiac cell sheets onto intestinal mesentery and confirm that these cardiac tubes exhibited pulsatile activity and generated an internal pressure. Cell sheets were created by culturing neonatal rat cardiac cells on temperature-responsive dishes. After harvesting, three cell sheets were stacked, and the triple-layered cell sheet was rolled around a section of endotracheal tube. The resulting construct was cultured to generate a cardiac tube. In the single-step group (n = 6), a cardiac tube was implanted onto the intestinal mesentery of a rat. In the double-step group (n = 6), a cardiac tube was implanted onto the intestinal mesentery of a rat, and another new cardiac tube was inserted into the original cardiac tube one day later. The pulsations and internal pressures of the implanted cardiac tubes were evaluated 1, 2 and 4 weeks after transplantation. Histology and immunohistochemistry were used to confirm whether vasculature was present in the cardiac tubes at 4 weeks after transplantation. We found that the cardiac tubes developed spontaneous pulsations from 1 week after transplantation. The average internal pressures of the cardiac tubes at 4 weeks after transplantation were 1.8 ± 1.0 mmHg in the single-step group and 2.5 ± 0.3 mmHg in the double-step group. The cardiac tubes in the double-step group contracted in response to electrical stimulation at 4 weeks after transplantation. Histological and immunohistochemical analyses revealed engraftment of the transplanted cardiac cell sheets and neovascularization of the cardiac tubes in both groups. Our findings demonstrate that it is feasible to generate functional cardiac tubes using the mesentery as a vascular bed. Further development of this technique will include the creation of a thicker tube, transplantation of the tube into major vessels and evaluation of the function of the tube under physiological conditions.

Long-term follow-up of Fontan completion in adults and adolescents.

BACKGROUND: The Fontan procedure is rarely performed in adults and adolescents in the present era. We review our results with the Fontan procedure in adolescents and young adults. METHODS: Between 1974 and 2010, 79 consecutive patients underwent the Fontan procedure at an age ≥ 15 years (mean age at Fontan operation, 20.3 years ± 4.5 years). Forty-five patients underwent atriopulmonary connection, 11 underwent the Bjork procedure, and 23 underwent total cavopulmonary connection. RESULTS: Ten hospital deaths (HDs) and/or early Fontan takedowns (TDs) occurred. The median follow-up period was 18.2 years (range, 0.6-37.6 years). The estimated freedom from death or TD rates was 79.7% at 5 years, 77.0% at 10 years, 73.9% at 15 years, and 63.9% at 20 years. Age was not a predictor of HD and/or TD. Freedom from death or TD after 1998 was 69.1% at 5 years, 69.1% at 10 years, and 69.1% at 15 years, and before 1997 was 82.3% at 5 years, 79.0% at 10 years, 75.5% at 15 years, and 65.1% at 20 years; there were no significant differences between the two groups. In 19 late-death patients, nine (47.4%) experienced sudden death. Among these patients, five had known arrhythmias before sudden death. CONCLUSIONS: In patients who were ≥15 years old, the surgical results of the Fontan operation were acceptable. Approximately half of the late deaths were sudden deaths, mainly occurring 10-20 years postoperatively.

[Surgical treatment for aortic valve endocarditis combined with bacterial meningitis and vertebral osteomyelitis;report of a case].

A 59-year-old man was referred to our hospital with disturbance of consciousness. Bacterial meningitis was diagnosed by a spinal tap, and penicillin sensitive Streptococcus pneumonia was detected by blood culture. Magnetic resonance imaging revealed a vertebral osteomyelitis. Treatment with antibiotics was started immediately. Four days after admission, congestive heart failure suddenly occurred. Echocardiography showed mobile vegetation on the aortic valve, and severe regurgitation. As acute heart failure could not be controlled, the aortic valve was replaced by ATS 22AP valve on the 7th day after admission. Antibiotic therapy was continued for 8 weeks. The postoperative course was uneventful.

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.

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.

[Re-operation of an aortic pericardial bioprosthesis 23-years after implantation; report of a case].

A 49-year-old female suffered from dyspnea on exertion and jaundice from June, 2009. She had undergone aortic valve replacement with Carpentier-Edwards pericardial bioprosthesis due to active infectious endocarditis 23-years previously. The echocardiography showed severe aortic stenosis with moderate regurgitation. She was diagnosed as having prosthetic valve malfunction. Re-replacement of the aortic valve with mechanical valve was successfully performed. As far as we can see, this is one of the longest-term cases of implantation of pericardial bioprosthesis.

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.

Coronary artery bypass grafting in a patient with polyarteritis nodosa presenting with acute myocardial infarction and multiple coronary aneurysms.

Polyarteritis nodosa (PAN) is a necrotizing form of vasculitis that affects small- and medium- sized vessels. Cases of ischemic heart disease involving coronary aneurysms in patients with PAN have been reported previously, but there have only been a few reports of coronary artery surgery for PAN-related coronary disease. A 46-year-old female with a history of PAN arrived at our emergency room due to cardiopulmonary arrest. After cardiopulmonary resuscitation, emergent coronary angiography was performed, because an electrocardiogram demonstrated ST segment elevation in leads V1 to V5. Coronary angiography revealed occlusion of the proximal right coronary artery and left anterior descending coronary artery as well as multiple coronary aneurysms. We performed emergent two-vessel coronary artery bypass grafting (the left anterior descending coronary artery and posterolateral branch of the circumflex system were treated with grafts from the left internal mammary artery and saphenous vein graft, respectively) under percutaneous cardiopulmonary support without cardiac arrest. The patient's postoperative course was uneventful, and postoperative coronary angiography revealed that the bypass grafts were patent. A review of the literature and a discussion of this case are also presented.