[Mitral Valve Replacement for Eclipsed Mitral Regurgitation with Multiple Episodes of Acute Exacerbation and Remission].

Eclipsed mitral regurgitation is a relatively new disease concept reported in recent years, of which is not fully elucidated. A 73-year-old female had repeated episodes of heart failure of unknown cause. During cardiac catheterization and echocardiography performed, mitral regurgitation suddenly worsened and improved in a few minutes. The patient was diagnosed as having eclipsed mitral regurgitation with multiple episodes of acute exacerbation and remission. Although mechanism of exacerbation remains unclear, morphological change of the left ventricle is likely to be a major cause, and mitral valve replacement seems better than plasty for prevention of recurrent heart failure. The patient underwent valve replacement using a bioprothesis and was discharged from the hospital on her own 24 days after surgery. Six months after the operation, she has been doing well without recurrence of heart failure.

[Acute Aortic Dissection with Rapidly Enlarged Aneurysm after Methicillin-resistant Staphylococcus Aureus Bacteremia].

The patient is a 62-year-old man. He was referred to our hospital from a nearby clinic with a complaint of chest and back pain, and was urgently admitted with a diagnosis of Stanford type A (Debakey typeⅢbR) acute aortic dissection. During the course of his treatment, he developed a urinary tract infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Thereafter, the patient developed bacteremia, and follow-up computed tomography( CT) showed a rapidly enlarging descending aortic aneurysm and a left external iliac artery( EIA) aneurysm. On day 49 after admission, thoracic endovascular aortic repair, left EIA resection, and right EIA-left femoral artery bypass were performed. However, a contrast-enhanced CT scan on day 70 of hospitalization revealed a type Ia endoleak and enlargement of the descending aortic aneurysm, so the patient underwent replacement of the descending aorta on day 84. Postoperatively, the patient needed time for recovery, but was discharged on day 158. Three years after discharge, there has been no recurrence of infection, and the patient has been visiting our outpatient clinic. We report a case of acute aortic dissection with rapidly enlarged aneurysm after MRSA bacteremia. This serious condition was succesfully cured with continued antibiotic treatment, two surgical resections and revascularization.

[Mitral Valve Regurgitation Exacerbated by Aortic Dissection:Report of a Case].

The patient was a 74-year-old woman who was originally followed up for hypertrophic cardiomyopathy and mitral regurgitation without subjective symptoms. With the onset of acute aortic dissection, the mitral regurgitation was exacerbated with systolic anterior motion. In addition to aortic dissection surgery, mitral valve surgery was performed. The mitral valve was approached through a right-sided left atrial incision and replaced with a bioprosthetic valve. For aortic dissection, ascending aortic replacement was performed. The postoperative course was uneventful, and the patient was discharged on foot after rehabilitation. Simultaneous mitral valve surgery for acute aortic dissection is rare, but by intervening simultaneously, we were able to achieve a favorable postoperative course.

Calcified Aortic Wall Removal for Dysphagia Aortica Caused by Chronic Traumatic Aortic Pseudoaneurysm.

In this study, we report a case of a 45-year-old man with dysphagia aortica secondary to chronic traumatic aortic pseudoaneurysm of the aortic isthmus. He had been involved in a motor vehicle accident 27 years earlier. Computed tomography demonstrated a severely calcified aortic pseudoaneurysm of the aortic isthmus that compressed the esophagus extrinsically. An invasive surgical procedure involving a graft replacement and removal of the calcified aortic wall released the esophageal compression and completely improved the patient's symptoms. To the best of our knowledge, a case of dysphagia aortica caused by calcified pseudoaneurysm has never been reported.

Ruptured type A aortic dissection with saddle pulmonary embolism-like appearance on computed tomography angiography.

We present a case of ruptured type A acute aortic dissection with pulmonary trunk compression by mediastinal hematoma. This condition mimicked a pulmonary embolism on the early arterial phase of computed tomography angiography, whereas the correct diagnosis was determined from the late arterial phase and unenhanced computed tomography. We highlight the importance of carefully interpreting triphasic computed tomography angiography to assess the status of aortic dissection.

[Adhesion Prevention Effect of Circular Pericardial Drainage].

Pericardial adhesions can pose serious problems during cardiac reoperation. Here, we report three cases where circular pericardial drainage (CPD) was performed during the initial surgery and no pericardial adhesions were found during reoperation. All three patients had initially undergone an aortic valve replacement with CPD. Case 1:An 80-year-old female was reoperated this time for an aneurysm of the ascending aorta. A replacement of the ascending aorta was performed. Case 2:A 76-year-old male underwent a second aortic valve repair indicated for prosthetic valve infection. Case 3:The patient was an 82-year-old female. This time, mitral valve replacement, indicated for severe mitral valve stenosis, was performed. In these three cases, there were almost no adhesions in the CPD route. The diaphragmatic pericardial surface, the oblique sinus of pericardium, and the lateral side of the left ventricle were also adhesion-free. CPD can effectively drain postoperative pericardial hemorrhage and thus prevent pericardial adhesions.

[Three-dimensional Anatomical Anastomosis in Total Arch Replacement].

The ascending aorta and the aortic arch curve 3-dimensionally from the right front of the heart to its left rear. If this curve is replaced or connected with a straight artificial graft, the curve will lose its natural shape. Here, we reconstructed the ascending aorta and the aortic arch with 2 different types of grafts, and devised a 3-dimensional(3D) structure by anastomosis. "3D anastomosis" first involves reconstructing the ascending aorta and the aortic arch with separate grafts. An oblique incision was then made at the proximal stump of the aortic arch graft so that its tip pointed to the right side of the patient. Similarly, an oblique incision was made at the distal stump of the ascending aorta graft so that its tip pointed to the anterior position of the patient. Then, the 2 grafts were anastomosed in a twisted manner of 90 degrees. Therefore, a 3D form was created from the right front of the heart to its left rear. We achieved good results in 14 patients using this method.

[Usefulness of echocardiography for detecting prosthetic valve dysfunction; report of a case].

A 78-year-old woman with a history of mitral valve stenosis underwent open mitral commissurotomy in 1976. In 1990, she underwent mitral valve replacement (Medtronic-Hall 29 mm), tricuspid annuloplasty(DeVega method), and pacemaker implantation for bradycardiac atrial fibrillation. However, in June 2012, she developed anemia of unknown cause. Prosthetic valve dysfunction was suspected, because intermittent changes in the left ventricular inflow was detected by echocardiography. Fluoroscopy actually confirmed the presence of prosthetic valve dysfunction. Therefore mitral valve re-replacement(ATS Medical, Inc. 29 mm) and tricuspid annuloplasty (Cosgrove ring 30 mm) were performed. Monitoring the changes in the left ventricular inflow is recommended when prosthetic valve dysfunction in a single leaflet is suspected.

[Early calcification of bioprosthetic valve in a hemodialysis patient with secondary hyperparathyroidism;report of a case].

Aortic valve replacement using CEP Magna 21 mm bioprosthetic valve was performed because of aortic valve stenosis in a 75-year-old man with maintenance dialysis. In the 39th postoperative month, the bioprosthetic valve malfunction due to calcification was noted, and it was replaced. Judging from the previously reported cases, malfunction of an artificial valve in the 39th month is thought to be relatively early. Early-stage calcification of a bioprosthetic valve is considered to be caused by secondary hyperparathyroidism due to artificial dialysis. Therefore, careful consideration is necessary in selecting an artificial valve in a dialysis patient. To prevent early-stage calcification of a bioprosthetic valve in a dialysis patient, strict control of parathyroid hormones, blood phosphorus and calcium levels is necessary. In addition, due to the attendant risk of calcification of bioprosthetic valves, mechanical valves are recommended to dialysis patients, who are expected to survive for more than 3 years and who are not expected to develop hemorrhagic complications.

Type A Acute Aortic Dissection in a Patient with Patent Ductus Arteriosus.

Cardiac or aortic surgeries requiring cardiopulmonary bypass in combination with patent ductus arteriosus in adults present a special problem that requires a tailored approach. We report a case of ruptured type A acute aortic dissection in a 73-year-old woman with patent ductus arteriosus. In this case, we highlight that transpulmonary direct ductus arteriosus closure and subsequent frozen elephant deployment with total arch replacement are reasonable and reliable treatments for type A acute aortic dissection in a patient with patent ductus arteriosus.

Chronic contained rupture of abdominal aortic aneurysm that developed from chronic abdominal aortic dissection.

A chronic contained rupture is an extremely rare subtype of abdominal aortic aneurysm rupture. We report the case of a 59-year-old man with a medical history of traumatic lumber fracture 7 years ago. He presented to us with an asymptomatic irregular abdominal aortic aneurysm, and surgery was performed 1 week after he was hospitalized. Based on the medical history, imaging, blood tests, and pathologic results, we determined that the chronic contained rupture progressed from a localized abdominal aortic dissection. This case illustrates the need to follow the morphology of aortic aneurysms if chronic abdominal aortic dissection is observed.

[Evaluation of a new method of pericardial drainage after cardiac surgery].

Recently pericardial drainage after cardiac surgery has been done using silicon tubes of small diameter. For more effective drainage, we set one of the drainage tubes circularly, coursing behind the left ventricle, through the transverse sinus, and ending at the right side of the atrium (circular pericardial drainage). As compared to conventional drainage using 28 Fr chloroethilene tubes, drainage time was shorter and no late tamponade had occurred. Circular pericardial drainage may be useful.

Management with closed irrigation for post-sternotomy mediastinitis: experience with the use of electrolyzed strong acid aqueous solution.

OBJECTIVE: The aim of this study was to assess the adequacy of our treatment strategy for patients with post-sternotomy mediastinitis. METHODS: Between May 1997 and December 2000, 1,045 consecutive adult cardiac operations were performed at our center. Mediastinitis occurred in 8 patients (0.77%) and as treatment, they underwent (1) aggressive debridement, (2) closed irrigation and drainage, and (3) transvenous administration of antibiotics. We irrigated the mediastinum with 0.1-1.0% povidone-iodine solution, alternating with electrolyzed strong acid aqueous solution. We subsequently reviewed the outcome after the closed irrigation treatment for patients with post-sternotomy mediastinitis. RESULTS: In four of the 8 patients, the culture specimen grew Methicillin-resistant Staphylococcus aureus. In the others, Serratia marcescens, Staphylococcus epidermidis, Pseudomonas aeruginosa and Gram-negative rods were cultured. The mean period between primary surgery and the diagnosis of mediastinitis was 16.3 (8 -57) days. The mean period between diagnosis of mediastinitis and the start of the irrigation treatment was 0.8 (0-3) days. The mean irrigation period was 30.0 (14-47) days. The irrigation complications were mild hepatic dysfunction in 2 patients, hyponatremia in 2 and protracted wound infection in 1. The hospital mortality was 1/8 (12.5%). Seven survivors are free from recurrent mediastinitis. CONCLUSIONS: Our experience of closed irrigation and drainage suggests that it can yield satisfactory results after post-sternotomy mediastinitis, comparable to other reported results with or without muscle flaps.

[Primary right ventricular malignant fibrous histiocytoma; report of a case].

Primary malignant fibrous histiocytoma located in the right side of the heart is extremely rare. We reported a case with literal reviews. A 71-year-old woman was admitted of faintness due to hypotension and marked edema of her lower extremity. With no time she was deteriorated into cardiogenic shock. Echocardiography demonstrated a tumor like mass which occupied her whole right ventricular cavity. Emergency tumor resection was carried out because of her status. Histological and immunohistochemical studies revealed the tumor was malignant fibrous histiocytoma. She died of pulmonary failure on nineteenth day after surgery.

Magnetic resonance angiography in coronary artery bypass grafting.

An attempt was made to reduce the incidence of perioperative stroke by detecting cerebrovascular disease with preoperative head and neck magnetic resonance angiography and by selecting the coronary artery bypass grafting technique. This strategy was used in 268 patients with ischemic heart disease who had undergone both head and neck magnetic resonance angiography before elective coronary artery bypass in our hospital between May 1997 and April 2001. In patients with significant stenosis or obstruction detected by head and neck magnetic resonance angiography, the findings were evaluated and cerebral blood flow was examined using brain single-photon emission computed tomography. In those with a high risk of cerebrovascular ischemia, off-pump coronary artery bypass was performed to maintain cerebral blood flow. No stroke occurred during surgery, and hemodynamic cerebrovascular ischemia was prevented in all 268 patients. Postoperative stroke occurred in 3 patients (1.1%), but the incidence of perioperative stroke was reduced.

Head and neck magnetic resonance angiography before coronary artery bypass grafting.

PURPOSE: To evaluate the incidence of vascular lesions in the head and neck by magnetic resonance angiography (MRA), and investigate the factors correlated with severe stenosis. METHODS: Elective coronary artery bypass grafting (CABG) was performed in 413 patients at our center between May 1997 and April 2001. We used MRA to detect head and neck vascular lesions, then evaluated the occlusive lesions and determined their prevalence. RESULTS: Neck MRA was performed in 335 patients and head MRA was performed in 335 patients. We found > or = 60% stenosis or total occlusion of the extracranial carotid and vertebral artery in 43 patients (12.8%) and > or = 60% stenosis or occlusion of the intracranial carotid and basilar artery, or stenosis accompanied by poor peripheral perfusion or occlusion of the cerebral arteries in 45 patients (13.4%). Occlusive lesions of the neck were significantly correlated with mean age, peripheral vascular disease (PVD), and old myocardial infarction. Occlusive lesions of the brain were significantly correlated with age, hypertension, PVD, and left main trunk disease. CONCLUSIONS: We found an equal incidence of intracranial and extracranial vascular lesions. Thus, searching for intracranial lesions is just as important as searching for extracranial lesions before CABG.