A Surviving Case of Myocardial Infarction with Ventricular Septal Rupture and Ventricular Aneurysm following Gastrointestinal Bleeding.

A 55-year-old man presented to the emergency department with worsening shortness of breath 1 month after a gastrointestinal bleed. He had congestive heart failure, and an electrocardiogram suggested ischemic heart disease involvement. Echocardiography revealed a ventricular septal defect complicated by a left ventricular aneurysm in the inferior-posterior wall. Conservative treatment was started, but hemodynamic collapse occurred on the third day of admission and coronary angiography revealed a revascularizing lesion in the right fourth posterior descending coronary artery. Subsequently, his hemodynamic status continued to deteriorate, even with an Impella CP® heart pump, so ventricular septal defect patch closure and left ventricular aneurysm suture were performed. His condition improved and he was discharged on day 23 of admission and was not readmitted within 6 months after the procedure. Hemodynamic management of ventricular septal defects requires devices that reduce afterload, and clinicians should be aware of the risk of myocardial infarction after gastrointestinal bleeding.

Risk Factors for Progression of Distal Deep Vein Thrombosis.

BACKGROUND: There is insufficient evidence regarding the optimal treatment method for distal deep vein thrombosis (DVT), including indications for anticoagulation therapy. Treatment results of patients with distal DVT were evaluated to clarify the risk factors that result in extension of distal DVT to the proximal vein and indications for anticoagulation therapy.Methods and Results:Among 430 patients with DVT between January 2018 and December 2019, 253 were diagnosed with distal DVT; 41 patients who had already started anticoagulation therapy were excluded, and the remaining 212 were included as study subjects. Anticoagulation therapy was not started immediately; conservative treatment with compression stockings was performed. Ultrasonography after 2 weeks revealed thrombus disappearance in 39 patients (21%), and thrombus reduction in 38 patients (20%). In contrast, extension of thrombus to the proximal vein was noted in 12 patients (6.3%) and anticoagulation therapy was commenced. After 3 months, the thrombus had disappeared in 75 patients (52%). No patient developed pulmonary thromboembolism during follow-up. With respect to the risk factors for extension to proximal vein during conservative treatment, active cancer (P=0.03), prolonged bed rest (P<0.01), and D-dimer level >8µg/mL (P=0.01) were identified. CONCLUSIONS: It is reasonable to consider anticoagulation therapy in distal DVT patients with active cancer, prolonged bed rest or high D-dimer level.

[Isolated Mitral Valve Replacement was Effective in Patient with Hypertrophic Obstructive Cardiomyopathy and Concomitant Mitral Regurgitation;Report of a Case].

This report presents a case of a 68-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) and concomitant mitral regurgitation (MR). Preoperative echocardiography showed stenosis of the left ventricular outflow tract (LVOT) and systolic anterior leaflet motion (SAM) of the mitral valve. She underwent mitral valve replacement( MVR) alone, and obstruction of LVOT was successfully released. Although a septal myectomy is the "gold standard" surgical therapy for HOCM, complications such as heart-block and ventricular septal perforation still remain. It was suggested that in some cases of HOCM complicated with MR, isolated MVR could be considered as the 1st-line surgical therapy.

[Comparison of Two Minimally Invasive Aortic Valve Replacement Approaches;Right Infra-axillary Thoracotomy versus Partial Sternotomy].

OBJECTIVES: Minimally invasive aortic valve replacement(AVR) is reported to show better postoperative outcomes than those associated with conventional AVR. We compared 2 minimally invasive approaches;right infra-axillary thoracotomy( TAX) and partial sternotomy( PS). METHODS: From January 2013 to December 2017, 54 patients underwent isolated AVR, of whom 14 were in TAX group and 28 were in PS group. Operative outcomes were compared between the 2 groups. RESULTS: Preoperative characteristics were similar between the groups. Cardiopulmonary bypass time and cross-clamp time were significantly longer in TAX group. Blood transfusion rates, however, were lower[ 5( 35.7%) versus 22 ( 78.6%):p=0.006] and ventilation time was shorter( median 4.0 versus 6.0 hours:p<0.001) in the TAX group. No mortality or stroke occurred in either group. CONCLUSIONS: Both TAX and PS AVR could be performed safely, with low mortality and morbidity. TAX was associated with a lower transfusion rate and a shorter ventilation time, and was supposed to be less invasive than PS.

Factors associated with a low initial cerebral oxygen saturation value in patients undergoing cardiac surgery.

Regional cerebral oximetry using near-infrared spectroscopy device, an INVOS 5100 C (Medtronic, Minneapolis, MN, USA), during cardiac surgery aims to avoid perioperative neurological impairment, especially during cardiopulmonary bypass. However, it is not uncommon to encounter critically low initial cerebral regional oxygen saturation or a low value unresponsive to intervention. Therefore, it is important to identify factors associated with low saturation value other than true cerebral hypoxia. We investigated the relationship between preoperative regional cerebral oxygen saturation and clinical variables during cardiac surgery. From January 2013 to May 2016, 462 patients underwent elective cardiac surgery. Patient's ≤12 years of age, with acute cerebral infarction, with previous intracranial hemorrhage or neurosurgery, with concomitant aortic surgery, and having off-pump coronary artery bypass surgery were excluded. The remaining 223 patients were monitored by intraoperative regional cerebral oximetry. Univariate analysis found that scalp-cortex distance, cerebrospinal fluid thickness, left ventricular ejection fraction, hemoglobin concentration, estimated glomerular filtration rate, and hemodialysis were significantly correlated with the initial regional oxygen saturation value. Multiple regression analysis revealed that scalp-cortex distance, left ventricular ejection fraction, hemoglobin, and hemodialysis remained as significant variables. A receiver operating characteristic analysis found that for a low initial regional oxygen saturation value of 40%, the thresholds of scalp-cortex distance, left ventricular ejection fraction, and hemoglobin concentration were 17.6 mm, 45.2%, and 7.5 g/dl, respectively. In conclusion, brain atrophy, poor left ventricular function, anemia, and hemodialysis were associated with low initial cerebral regional oxygen saturation values in adult cardiac surgery patients.

Daily transient discontinuation of extracorporeal LVAD to prevent thromboembolism of mechanical aortic valve prosthesis.

Patients with mechanical aortic valves are generally contraindicated for left ventricular assist device (LVAD) insertion because the prosthetic valve often becomes fixed in closed position. A 41-year-old woman with mechanical aortic valve prosthesis experienced sudden chest pain and developed cardiogenic shock. A paracorporeal pulsatile LVAD and a monopivot centrifugal pump as a right VAD (RVAD) were implanted. The mechanical aortic valve was intentionally left in place. Soon after the operation, LVAD support was discontinued daily for few seconds to allow the mechanical aortic valve to open and to avoid thrombus formation. The patient was successfully weaned off RVAD and received anticoagulation therapy with warfarin. On postoperative day 141, she was transferred to a university hospital where a HeartMate II LVAD was implanted, and the aortic valve was successfully replaced with a bioprosthetic valve. The patient is currently awaiting heart transplantation.

Novel Technique Using Polyester Fabric and Fibrin Sealant Patch for Acute Aortic Dissection.

We describe a simple and effective technique for acute aortic dissection using a combination of polyester fabric and a fibrin sealant patch (FSP) to achieve effective reinforcement and haemostasis of the aortic stump. Firstly, the 0.61mm thick knitted polyester fabric sheet was cut to half of the size of the FSP. Next, fibrin glue was sprayed onto the collagen layer of the FSP. Subsequently, a fabric sheet was placed upon it, and the FSP was put together with the irrigated collagen layer, and then completely dried to bind the patch. As a result, the dry fibrinogen/thrombin layers, as an adhesive surface, faced outward. This patch was trimmed to a 10-15-mm-wide strip. The composite patch was inserted into the false lumen. The stump was gently pressed to fix the aortic intima and adventitia. There are several advantages: the combined patch can be prepared during systemic cooling, and therefore can minimise the circulatory arrest time; secondly, the false lumen is not directly exposed to fibrin glue and so the risk of embolism is extremely low; thirdly, the expected haemostatic effect is greater as FSP lines the exterior of the intima, achieving haemostasis for suture holes.

A Case of Vascular Graft Infection Caused by Haemophilus parainfluenzae.

Haemophilus parainfluenzae is a gram-negative coccobacillus that is a part of the normal flora in the human upper airway and sometimes causes infective endocarditis. We present a case of a 68-year-old Japanese man who had vascular graft infection caused by H. parainfluenzae 4 years after surgery for chronic aortic dissection.

Transareolar Video-Assisted Approach to the Atrial Septal Defect and Tricuspid Valve.

Minimally invasive atrial septal defect closure and tricuspid annuloplasty in female patients are normally performed through a right submammary anterior minithoracotomy approach. However, when the aortic root is located higher, the direction of aortic cannulation becomes not ideal through the submammary incision. In such cases, transareolar approach is useful. Through this approach, aortic cannulation and tricuspid operation can be performed with endoscopic assistance, and ASD closure can be performed under direct vision.

Outcomes of patients who declined surgery for acute Stanford type A aortic dissection with patent false lumen of the ascending aorta.

OBJECTIVES: This study aimed to evaluate the outcomes of patients who did not undergo initial aortic surgery for acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: We identified 195 patients with acute type A aortic dissection with a patent ascending false lumen between January 1998 and March 2016. Of these, 137 underwent aortic surgery, 16 died before surgery and 42 declined aortic surgery. The ages of the patients who underwent and those who declined aortic surgery were 60.0 ± 10.6 years and 72.3 ± 12.4 years, respectively. The mortality rate of those who underwent and those who declined aortic surgery was 15 and 62% at 30 days and 19% and 67 at 90 days, respectively ( P < 0.0001). In the 58 patients who did not undergo initial aortic surgery, the maximum aortic diameter was correlated with survival ( P = 0.0037). At follow-up (3.7 ± 4.5 years; range 0-16.4 years), survival at 1, 5 and 10 years in those who underwent and those who declined initial aortic surgery was 78, 68 and 49%, and 29, 24 and 12%, respectively ( P < 0.0001). CONCLUSIONS: In this study of patients with acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta, the mortality of those who declined initial aortic surgery was 62% at 30 days and 67% at 90 days, respectively, and a smaller aortic diameter was significantly associated with better survival.

Surgical removal of extensive left pulmonary vein stump thrombus after pulmonary lobectomy: a rare cause of acute cerebral embolism.

A 46-year-old woman presented with loss of consciousness and was diagnosed with acute cerebral embolism. She had undergone left upper lobectomy for primary lung cancer 6 months before this event. Transesophageal echocardiography and computed tomography showed a large mobile thrombus in the left upper pulmonary vein (LSPV). An emergent operation was performed through a median sternotomy. Cardiopulmonary bypass was performed and the heart was arrested, and the LSPV was incised. A fresh thrombus had formed in the stump of the LSPV and was removed successfully. The postoperative course was uneventful. During a 1 year of follow-up, there was no recurrence of the thrombus.