[Experience with a New Negative Pressure Incisional Wound Management System in Cardiac Surgery].

We report on the efficacy of the Prevena incisional wound management system, a negative pressure wound care system, in patients at a high risk of wound infection following cardiac surgery. METHODS: Ten patients with a mean Fowler risk score of 4.6( 1.6~9.9) were included. The Prevena system was applied immediately after surgery and used for 5 days while negative pressure of -125 mmHg was continuously applied, and the condition of the wound and surrounding skin was evaluated immediately after removal of the Prevena system. RESULT: Ten patients had completely healed wounds, and no skin damage around the wound due to negative pressure after removal of the Prevena system was observed. No skin damage was observed around the wound after removal of the Prevena system, and no wound complications occurred until discharge. CONCLUSIONS: The Prevena system is safe, easy to use, and useful for wound healing in patients at a high risk for wound complications after cardiac surgery.

[Transprosthetic Cuff Leakage of the MITRIS RESILIA Mitral Valve During Mitral Valve Replacement:Report of a Case].

An 82-year-old woman was referred to our hospital because of severe mitral valve regurgitation( MR)with symptoms of heart failure. Preoperative transesophageal echocardiography( TEE) showed P2 prolapse due to chordal rupture, severe calcification of P2, and mild tricuspid valve regurgitation. The patient underwent mitral valve replacement using the MITRIS RESILIA mitral valve and tricuspid annuloplasty. Intraoperative TEE showed a mild regurgitation from the cuff on the A1P1 side at the mitral valve position. After the second aortic declamping, 4-0 prolene felted mattress suture was placed on the needle hole in the cuff. In repeat TEE, regurgitation improved to trace. Postoperative echocardiography confirmed disappearance of transprosthetic cuff leakage at the mitral valve, and the patient was discharged on postoperative day 36. We experienced a transprothetic cuff leakage, which is the first case on the MITRIS RESILIA mitral valve.

[Mitral Regurgitation Repaired by Papillary Heads Optimization Technique].

Functional mitral regurgitation( FMR) is a risk factor that increases the mortality rate and incidence of heart failure. Surgical intervention is important. Mitral valve (MV) reconstruction can preserve the valvular apparatus;no anticoagulation therapy is required, left ventricular function is preserved. Some studies have reported a high mitral regurgitation (MR) recurrence rate with only restrictive MV annuloplasty for FMR. Therefore, various reconstructive techniques for FMR have been developed. Papillary heads optimization( PHO),reported by Komeda, is one technique. We performed MV repair with the PHO technique in 3 FMR cases. The 1st case had severe tethering and annulus dilatation due to chronic MR, the 2nd and 3rd were caused by ischemic and dilated cardiomyopathy (DCM),respectively. In the early postoperative period, we achieved technical success in all cases. However, 9 months later, moderate MR had recurred in the 3rd case. Geometric measurements with transthoracic echocardiography showed an increase of the papillary muscle distance between the papillary muscle origin and the posterior MV anuulus. The correction of papillary muscles position by PHO might have failed by the progress of DCM, and MR recurred. The operative method and indication for DCM should be carefully considered.

[Early and Long Term Outcomes of Surgery for Acute Type A Aortic Dissection Complicated with Organ Malperfusion].

OBJECTIVE: The purpose of this study was to evaluate early and long term outcomes of surgery for acute type A aortic dissection complicated with organ malperfusion. METHOD: From January 2001 to October 2015, 336 consecutive patients (mean age 68.6±12.2, male 172) underwent surgery for acute type A aortic dissection at out center. Early and late outcomes were compared between patients accompanied with and without organ malperfusion. RESULTS: Preoperative organ malperfusion was observed in 76 patients( 22.6%). That consisted of 38 neurological systems, 13 coronary, 8 visceral, and 26 extremities. Nine patients had 2 organ malperfusion. In-hospital mortality was 22.4% and 6.5% in patients with and without organ malperfusion, respectively. Multivariate logistic analysis showed preoperative organ malperfusion was a significant risk factor for in-hospital mortality (Odds ratio 3.59, 95% confidence interval 1.56~8.28, p<0.01). Five year survival rate of hospital survivors were 84.5±5.5% and 80.9±3.3% with and without organ malperfusion (p=0.51). CONCLUSIONS: Although organ malperfusion is still associated with high mortality, however, acceptable long term outcomes could be obtained if organ malperfusion is treated appropriately. Ischemic organ oriented approach might be very important to improve surgical outcomes of these critically ill conditions.

Successful sutureless repair of multiple left ventricular free wall ruptures due to Takotsubo cardiomyopathy: a case report.

BACKGROUND: Takotsubo cardiomyopathy (TCM) is a temporary and reversible systolic abnormality of the left ventricular apical area resembling a myocardial infarction. Cardiac rupture due to TCM is a rare but fatal complication. Without cardiac surgery, 94% of patients with left ventricular free wall rupture (LVFWR) due to TCM die. Furthermore, successful surgical cases are rare. We report herein the successful treatment of multiple LVFWRs due to TCM using a sutureless repair. CASE PRESENTATION: An 80-year-old man quarreled with his daughter and had a sudden onset of chest pain. He was transferred to our hospital in shock. Electrocardiography showed ST elevation and contrast-enhanced computed tomography revealed a bloody pericardial effusion. Emergent coronary angiography showed no significant stenosis. Cardiac arrest ensued because of cardiac tamponade. Emergent surgery was undertaken and three oozing lacerations on the lateral and inferior walls were noted. A sutureless repair was performed using TachoSil® patches. We also applied Surgicel Nu-Knit® absorbable hemostat with Hydrofit® where TachoSil® failed to completely adhere because of hematoma formation and achieved complete hemostasis. We diagnosed the ruptures due to TCM according to the Mayo criteria. The patient was discharged on postoperative day 71. CONCLUSIONS: A sutureless repair using TachoSil® patches and Surgicel® with Hydrofit® is a minimally invasive and effective method for the treatment of multiple LVFWRs due to TCM.

[New concept of mitral valve repair for posterior leaflet prolapse].

BACKGROUND: Conventional repair of posterior mitral valve prolapse involves quadrangular resection and sliding plasty. However, these 2 methods require annular plication and useful leaflet tissue is sacrificed. METHODS: Our concept is to make an ideally shaped posterior leaflet without annular plication. When the leaflet is not high, we select triangular resection( TRR). For a high leaflet, we developed hourglass resection (HGR). The hourglass shape consists of 2 triangles:the upper inverted triangle is resected and the lower triangle is resected and sutured to the annulus. From 2007 to 2012, 65 patients with mitral regurgitation (MR) with leaflet prolapse were repaired. 49 patients who had posterior leaflet prolapse were analized in this study. The mean age was 61.7±11.5 years and 67.3% were men. RESULTS: All patients underwent successful repair. There were no hospital deaths, or no systolic anterior motion. In 1 patient, repair was repeated 1 month post-operatively. The mean follow-up period was 2.6±1.5 (0.1 ~ 4.9) years. There were no late deaths. The most recent echocardiogram revealed no MR in 36, mild MR in 12, and moderate MR in 1 cases. CONCLUSION: The short-term results of our strategy for posterior leaflet repair are good.

Mitral regurgitation indirectly caused by giant left atrial myxoma: a case report.

Cardiac myxoma is a benign primary cardiac tumor. Herein, we report a case of mitral regurgitation due to annular dilatation caused by giant left atrial myxoma. The transthoracic echocardiogram performed in a 65-year-old man who suffered from worsening exertional dyspnea detected a large mass of 81 × 31 mm in the left atrium, causing functional severe mitral stenosis. Radical mass resection was performed. After removal of the aortic clamp, an intraoperative transesophageal echocardiogram revealed moderate mitral regurgitation due to annulus dilatation. Mitral annuloplasty was performed, and mitral regurgitation was controlled. The mass was diagnosed as myxoma histologically. A large myxoma that affects mitral annulus dilatation is rarely reported. Mitral regurgitation may be masked by the presence of a large myxoma. Therefore, it should be carefully evaluated after resection, and mitral annuloplasty should be considered in the presence of significant mitral regurgitation due to mechanical annulus dilatation caused by myxoma.

Prosthetic vascular graft rupture caused by claw-type rib fixation strut: a case report.

A 66-year-old-man who had undergone partial aortic arch and descending aortic graft replacement for a dissecting aortic aneurysm presented to our hospital with pain and beating swelling of his left back shoulder. Enhanced computed tomography and aortic angiography revealed graft rupture caused by one of the claws of a rib fixation strut. Furthermore, another claw had invaded a lung. We performed emergency thoracic endovascular aortic repair, and removed all of the struts 3 weeks later. Claw-type rib fixation struts have the potential to injure other organs, including prosthetic grafts. Careful follow-up is mandatory after implantation of this type of strut.

Interrupted commissural band annuloplasty for degenerative mitral valve disease.

BACKGROUND: Mitral annuloplasty is useful for treating degenerative mitral valve disease. Although the incidence of complications is low, prosthetic ring-related complications can occur. Hemolysis and mitral stenosis are serious complications requiring reoperation. Limited use of prosthetic material could decrease the risk for complications. Commissural annuloplasty has been reported by Kay and Reed; their techniques involve suture plication. To prevent dehiscence, we selected short bands and compared the echocardiographic changes between this method and the Cosgrove ring. METHODS: Three sutures are placed in the commissures using two bands, which shortens the annular length by 60%. We performed this interrupted commissural band annuloplasty (iCBA) in 63 patients and used Cosgrove bands for 58 patients. RESULTS: Clinically, for iCBA and Cosgrove groups, respectively, hemolysis with mild mitral regurgitation occurred in 0 and 2 cases (p=0.084), and mitral stenosis due to pannus formation occurred in 0 and 1 case (p=0.224). There was a trend toward a lower ring-related complication rate in the iCBA group. On echocardiography, for the iCBA and Cosgrove groups, respectively, the maximum anterior-posterior distance of the annulus in diastole was 3.1±0.7 mm and 2.6±0.4 mm (p<0.001), maximum opening angle of the posterior leaflet was 85.7±17.3 degrees and 103.4±20.1 degrees (p<0.001), and coaptation distance was 11.6±3.7 mm and 8.4±2.6 mm (p<0.001). CONCLUSIONS: The iCBA method prevented posterior leaflet tethering, kept the coaptation distance deep on echocardiography, and was associated with lower trends of ring-related complications. Because the posterior side of the annulus was not reconstructed, iCBA is suitable for fibroelastic deficiency, rather than for Barlow's disease.

Aggressive atrial volume reduction for bilateral giant atria improves respiratory function.

Giant bilateral atria with mitral and tricuspid regurgitation can cause postoperative respiratory dysfunction. In this article, we describe a case of giant atria with poor respiratory function that was improved by atrial volume reduction. A 79-year-old woman was referred to our institution for valve surgery. Her vital capacity was 1,080 mL. The mitral and tricuspid valves were repaired during surgery. We removed a circular section of the left atrial wall. The right atrial wall and interatrial septum were removed; this improved her vital capacity to 1,370 mL. We conclude that aggressive volume reduction of both atria improves respiratory function.

A single papillary muscle with chordal rupture in an adult.

A single papillary muscle (SPM) is a rare anomaly in normal adults. It is sometimes associated with a complete common atrioventricular canal. Chordal rupture combined with a single papillary muscle in an adult has not been reported. We repaired the mitral valve with chordal replacement, although this was technically difficult, because the decision to place an artificial chordal attachment on the papillary muscle plays an important role. This report presents successful chordal replacement and band annuloplasty in a case of chordal rupture with a single papillary muscle. A surgical tip for chordal replacement with a single papillary muscle is to suture artificial chords on the same side of the SPM head as the affected side of the mitral valve, considering the direction of pull of the artificial chords.