Surgical treatment for degenerative mitral stenosis associated with aortic valve stenosis: A case report.

We report a 73-year-old female who underwent mitral valve replacement for degenerative mitral stenosis (DMS) and aortic valve replacement for aortic valve stenosis. She was transferred to our hospital because of congestive heart failure. Transthoracic echocardiogram demonstrated severe mitral valve stenosis and aortic valve stenosis. Transesophageal echocardiogram (TEE) revealed severe mitral annular calcification (MAC) and calcification of the anterior mitral leaflet without commissure fusion. The diagnosis of DMS associated with MAC and aortic valve stenosis was made. Since she did not have other significant comorbidities except diabetes mellitus and hypertension, open-heart surgery for double valve replacement was scheduled by our heart team. Complete resection of the calcium bar and annulus reconstruction with an autologous pericardium allowed safe mitral valve replacement with a mechanical valve. Concomitant aortic valve replacement with a mechanical valve was carried out for aortic valve stenosis. Intraoperative TEE demonstrated good left ventricular function without perivalvular leakage in both mitral and aortic prosthetic valves. The postoperative course was uneventful, and the patient was discharged from the hospital. Surgical intervention may be one of the alternative treatments for elderly patients with degenerative mitral stenosis and MAC. Learning objective: Degenerative mitral stenosis (DMS) associated with mitral annular calcification (MAC) is a severe heart valve disease in the elderly population in developed countries. The prognosis of patients with severe DMS is poor, and open-heart surgery for elderly patients with MAC is especially challenging from a surgical point of view. We report a surgical treatment for a patient with DMS and aortic valve stenosis considering the patient's comorbidities and extent of MAC.

Mitral valve repair for infective endocarditis: Kobe experience.

OBJECTIVES: We retrospectively analyzed our experience of mitral valve repair for native mitral valve endocarditis in a single institution. METHODS: From January 1991 to October 2011, 171 consecutive patients underwent surgery for infective endocarditis. Of these, 147 (86%) had mitral valve repair. At the time of surgery, 98 patients had healed (group A) and 49 had active infective endocarditis (group B). Repair procedures included resection of all infected tissue and thick restricted post-infection tissue, leaflet and annulus reconstruction with treated autologous pericardium, chordal reconstruction with polytetrafluoroethylene sutures, and ring annuloplasty if necessary. Fifty-two (35%) patients required concomitant procedures. The study endpoints were overall survival, freedom from reoperation, and freedom from valve-related events. The median follow-up was 78 months. RESULTS: There was one hospital death (hospital mortality 0.7%). Survival at 10 years was 88.5% ± 3.5% with no significant difference between the two groups (p = 0.052). Early reoperation was required in 4 patients in group B due to persistent infection or procedure failure. Freedom from reoperation at 5 years was 99% ± 1.0% in group A and 89.6 ± 4.0% in group B (p = 0.024). Event-free survival at 10 years was 79.3% ± 4.8% (group A: 83.4% ± 5.9%, group B: 72.6% ± 6.9%, p = 0.010). CONCLUSIONS: Mitral valve repair was highly successful using autologous pericardium, chordal reconstruction, and ring annuloplasty if required. Long-term results were acceptable in terms survival, freedom from reoperation, and event-free survival. Mitral valve repair is recommended for mitral infective endocarditis in most patients.

[Early Postoperative Hemodynamics of Mitral Valvuloplasty Using Colvin-Galloway Future Band].

The Colvin-Galloway( CG) Future annuloplasty band is a new semirigid partial band, which was introduced in 2012 in Japan. A total of 60 consecutive patients who underwent mitral valve repair with the CG Future Band were assessed by echocardiography in terms of residual mitral regurgitation and diastolic mitral function postoperatively. Intraoperative 3-dimensional echocardiography beautifully demonstrated the physiological change of the aortic curtain during the cardiac cycle. 30 mm was used in 18 patients, 32 mm in 17, 28 mm in 15, 34 mm in 5, 36 mm in 2, and 26 mm in 2. There were 2 patients with mild residual mitral regurgitation and 58 patients with less than mild. The mean gradient of diastolic mitral pressure gradient was 2.8±1.3 mmHg. Early results of mitral valve repair with a CG Future Band were acceptable in terms of residual mitral regurgitation and diastolic mitral function after repair.

Novel device that produces carbon dioxide mist for myocardial infarction treatment in rats.

BACKGROUND: Carbon dioxide (CO(2)) baths have been used to treat a variety of diseases, but developing an artificial bath of highly concentrated CO(2) is difficult. Here, we tried the efficacy of a novel device instead of a CO(2) bath. METHODS AND RESULTS: Using a device equipped with double fluid nozzles, CO(2) gas and H(2)O were compounded and compressed at 4 barometric pressures. As a result, CO(2) gas was dissolved in H(2)O, which contained a few micrometers of CO(2) particles, namely, a CO(2) mist. Wistar rats with myocardial infarction (MI) by ligation of the left coronary artery were percutaneously administered CO(2) mist or CO(2) gas alone or no treatment for 30 min daily. With regard to tissue blood flow during treatment, the group treated with CO(2) mist had significantly increased tissue oxygenated hemoglobin levels and tissue saturation levels, and significantly decreased deoxygenated hemoglobin levels compared with the group treated with CO(2) gas. After 4 weeks treatment, the group treated with CO(2) mist had a significantly improved ejection fraction by echocardiography compared with the untreated group. Interestingly, the group treated with CO(2) mist had significantly increased nitrate concentrations in serum and vascular endothelial growth factor mRNA expression levels in the myocardium compared with the untreated group. CONCLUSIONS: Our new mist production device may be potentially useful for the treatment of heart failure caused by MI.

Platypnea-orthodeoxia diagnosed by sitting transesophageal echocardiography.

Platypnea-orthodeoxia is a rare syndrome presenting with dyspnea and cyanosis induced by an upright position and relieved by recumbency. We report a patient with an excessively enlarged aortic root who had critical hypoxia due to a paradoxical shunt through the patent foramen ovale only when seated. The postural changes of the shunt, caused by changes in posture, were dynamically detected by transesophageal Doppler echocardiography. We believe that this syndrome should be considered when patients with aortic root dilatation present with inexplicable hypoxia, and that transesophageal Doppler echocardiography in the sitting position can be useful for detecting platypnea-orthodeoxia syndrome.

Pravastatin accelerates ischemia-induced angiogenesis through AMP-activated protein kinase.

Statins exert pleiotropic effects on the cardiovascular system, in part through an increase in nitric oxide (NO) bioavailability. In this study, we examined the role of pravastatin in ischemia-induced angiogenesis. Unilateral hindlimb ischemia was surgically induced in C57BL/6J mice. Phosphorylation of AMP-activated protein kinase (AMPK), acetyl-CoA carboxylase (ACC) and endothelial NO synthase (eNOS) was increased in ischemic tissues. Furthermore, mice treated with pravastatin showed higher increases in phosphorylation than did untreated mice. Laser Doppler analysis has shown that pravastatin treatment accelerates the development of collateral vessels and angiogenesis in response to hindlimb ischemia. Capillary density in the ischemic hindlimb was also increased by pravastatin treatment. An in vitro study on human umbilical vein endothelial cells (HUVECs) revealed that pravastatin increased the phosphorylation of AMPK. Pravastatin-induced phosphorylation of eNOS, one of the downstreams of AMPK, was inhibited by compound C, an AMPK antagonist. The increased migration and tube formation of HUVECs by pravastatin were significantly blocked by compound C treatment. The accelerated angiogenesis by pravastatin after hindlimb ischemia was significantly reduced after treatment with compound C. Thus, ischemia induced AMPK phosphorylation in vivo. Furthermore, pravastatin could also activate AMPK in vivo and in vitro. Such phosphorylation results in eNOS activation and angiogenesis, which provide a novel explanation for one of the pleiotropic effects of statins that is beneficial for angiogenesis.

Cardiac and autonomic nerve function after reduced-intensity stem cell transplantation for hematologic malignancy in patients with pre-transplant cardiac dysfunction.

Recent reports have shown that cardiomyopathy caused by hemochromatosis in severe aplastic anemia is reversible after reduced-intensity allogeneic stem-cell transplantation (RIST). We comprehensively evaluated cardiac and autonomic nerve function to determine whether cardiac dysfunction due to causes other than hemochromatosis is attenuated after RIST. In five patients with cardiac dysfunction before transplant, we analyzed the changes in cardiac and autonomic nerve function after transplant, using electrocardiography (ECG), echocardiography, radionuclide angiography (RNA), serum markers, and heart rate variability (HRV), before and up to 100 days after transplant. There was no significant improvement in cardiac function in any patient and no significant alteration in ECG, echocardiogram, RNA, or serum markers. However, on time-domain analysis of HRV, the SD of normal-to-normal RR intervals (SDNN) and the coefficient of variation of the RR interval (CVRR) decreased significantly 30 and 60 days after transplant (P = 0.04 and 0.01, respectively). Similarly, on frequency-domain analysis of HRV, low and high frequency power (LF and HF) significantly and temporarily decreased (P = 0.003 and 0.03, respectively). Notably, in one patient who had acute heart failure after transplantation, the values of SDNN, CVRR, r-MSSD, LF, and HF at 30 and 60 days after transplantation were the lowest of all the patients. In conclusion, this study suggests that (a) RIST is well-tolerated in patients with cardiac dysfunction, but we cannot expect improvement in cardiac dysfunction due to causes other than hemochromatosis; and (b) monitoring HRV may be useful in predicting cardiac events after RIST.

Multiple cardiac thrombi and thromboembolism in a heparin-induced thrombocytopenia antibody-positive patient with heart failure.

A 49-year-old Japanese man presented with orthopnea and edema in both legs. He was diagnosed with congestive heart failure with triple-vessel coronary artery disease. Low antithrombin and left ventricular systolic dysfunction were possible causes of his hypercoagulable state. Echocardiography revealed thrombi in the left ventricle and left trium, poor left ventricular contractility, and a normal mitral valve. Electrocardiogram revealed normal sinus rhythm. We found small infarctions of the brain and spleen in the computed tomography. The heparin treatment of cardiac thrombi is useless because the patient had heparin-induced thrombocytopenia antibody. We removed thrombi in the left ventricle and left atrium by thrombectomy and performed coronary artery bypass graft. Warfarin was administered for anticoagulation. He recovered completely and is now doing well. Our experience indicates that poor cardiac function can together cause multiple cardiac thrombi and subsequent thromboembolism without mitral stenosis or atrial fibrillation.

Impaired coronary circulation in patients with apical hypertrophic cardiomyopathy: noninvasive analysis by transthoracic Doppler echocardiography.

OBJECTIVES: We designed this study to examine the characteristics of coronary circulation in patients with apical hypertrophic cardiomyopathy (ApHCM) using noninvasive transthoracic Doppler echocardiography (TTDE). BACKGROUND: Recent advances in TTDE have allowed noninvasive assessment of coronary circulation by the measurement of coronary flow velocity (CFV) patterns and coronary flow velocity reserve (CFVR). However, there have been no previous studies evaluating coronary circulation in ApHCM. METHODS: We analyzed CFV and CFVR in the left anterior descending coronary artery (LAD), and apical wall thickness in the left ventricle, in 10 ApHCM subjects and 10 control subjects. Mean diastolic velocity (MDV) and time from the beginning of diastole to peak velocity (TPV), and CFVR, defined as a ratio of drug-induced hyperemic to basal MDV, were measured. RESULTS: At baseline, MDV was higher, and TPV was longer, in ApHCM subjects than in control subjects (29 +/- 5.7 versus 19 +/- 6.5 cm/sec; p < 0.01 and 5.2 +/- 1.0 versus 3.5 +/- 0.6 msec; p < 0.005, respectively). CFVR in ApHCM subjects was significantly lower than in control subjects (1.9 +/- 0.4 versus 3.1 +/- 0.8; p < 0.005). CFVR and basal MDV in ApHCM subjects showed significant correlations with apical/posterior wall thickness ratio [CFVR; r =-0.84, p < 0.01 and MDV; r = 0.74, p < 0.05, respectively]. CONCLUSION: Noninvasive coronary flow assessment by TTDE revealed an impaired coronary circulation with reduced CFVR, high MDV at baseline and prolonged TPV. These results suggest that these characteristics of coronary circulation may provide an additional index for the assessment of ApHCM.

Noninvasive coronary flow velocity reserve measurement in the posterior descending coronary artery for detecting coronary stenosis in the right coronary artery using contrast-enhanced transthoracic Doppler echocardiography.

BACKGROUND: Coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) has been found to be useful for assessing left anterior descending coronary artery (LAD) stenosis. However, this method has been restricted only for the LAD. The purpose of this study was to detect severe right coronary artery (RCA) stenosis by CFVR measurement using contrast-enhanced TTDE. METHODS: In 60 consecutive patients with angina pectoris (mean (SD) age: 60 (11), 18 women), coronary flow velocities in the RCA were recorded in the postero-descending coronary artery by contrast-enhanced TTDE at rest and during hyperemia induced by intravenous infusion of adenosine triphosphate (140 mcg/ml/kg). CFVR was calculated as the ratio of hyperemic to basal peak and mean diastolic flow velocity. CFVR measurements by TTDE were compared with the results of coronary angiography performed within 1 week. RESULTS: Coronary flow velocity was successfully recorded in 49 (82%) of the 60 patients with contrast agent. CFVR (mean (SD)) was 1.4 (0.4) in patients with, and 2.6 (0.6) in patients without significant stenosis in the RCA (%diameter stenosis > 75%, P < 0.001). Using the cutoff value 2.0 for CFVR in the RCA, its sensitivity and specificity in detecting significant stenosis in the RCA were 88% and 91%, respectively. CONCLUSION: CFVR measurement in the postero-descending coronary artery by contrast enhanced TTDE is a new, noninvasive method to detect significant stenosis in the RCA.

Unruptured aneurysm of the sinus of valsalva with Behçet's disease.

A 52-year-old Japanese man who had suffered from Behçet's disease since the age of 45 years was admitted to hospital for evaluation of syncope and heart murmur. Echocardiography and aortography revealed severe aortic regurgitation and cystic masses under the right coronary cusp and the left ventricular outflow tract, but no shunt jet. He was diagnosed with unruptured aneurysm of the sinus of Valsalva, and surgical closure of the orifice of the aneurysm was performed. The diameter of the orifice was 11 mm and the aneurysm was 15 mm in depth, and consisted of 2 chambers. Because the aortic regurgitation was reduced after patch closure of the orifice, aortic valve replacement was not performed. Unruptured aneurysm of the sinus of Valsalva is a rare clinical lesion, but patients with active inflammatory disease of the aorta, such as in Behçet's disease, should have periodic echocardiography for early detection of an aneurysm or valvular involvement, even if there are not any symptoms.