ABSTRACT
Primary repair of the tetralogy of Fallot with absent pulmonary valve syndrome (TOF/APV) is associated with high mortality rates of 17-33%, especially in neonates. Our standard strategy involves a staged repair with a first palliation, performed during the neonatal period, that includes main pulmonary septation with an ePTFE patch, pulmonary arterioplasty for reduction of vascular dilation, and a modified Blalock-Taussig shunt. We performed successful repairs on two neonates with TOF/APV, one symptomatic and the other non-symptomatic, with this strategy. Case 1 : A 7-day-old boy had TOF/APV, with progressively worsening respiratory distress. His left bronchi, superior vena cava and left atrium were compressed by a dilated pulmonary artery, which was repaired by emergency surgery. Decreasing the diameter of the pulmonary artery (PA index from 2,550 to 525) relieved the compressed organs. Case 2 : A 16-day-old boy with TOF/APV with a main pulmonary artery that increased in diameter from 8 to 17 mm in the course of a single day. He was treated in the same fashion as Case 1. At 1 year of age, an intracardiac repair with tricuspid anuuloplasty was performed successfully. This strategy is much safer than a primary repair and is a good choice for neonatal repair of TOF/APV.
ABSTRACT
A 29-year-old woman, who had been diagnosed with Ebstein's anomaly associated with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White (WPW) syndrome, was referred to our hospital for treatment of congestive heart failure and tachycardia. She had undergone a catheter ablation for WPW syndrome at the age of 28 years. Subsequently, surgical treatment for Ebstein's anomaly was indicated because of persistent symptoms of heart failure due to tricuspid regurgitation (TR). The echocardiogram and pathologic findings corresponded to Ebstein's anomaly of the Carpentier type B classification, with severe displacement of the septal and posterior leaflets resulting in moderate TR. A mobile anterior leaflet of sufficient size without a cleft enabled us to successfully perform Hetzer's procedure. In this procedure, the large mobile anterior leaflet was approximated to the opposing true tricuspid annulus with a mattress suture of 3-0 polypropylene passed from the anterior leaflet annulus to the true tricuspid annulus at the site of atrialized right ventricle near the coronary sinus. The postoperative course was uneventful, and the cardiothoracic ratio reduced from 56% to 48% with mild TR. In this adult case of Carpentier's type B adult Ebstein's anomaly, Hetzer's procedure allowed reconstruction of the tricuspid valve mechanism of “leaflet-to-septum” coaptation at the level of the true annulus by approximating the anterior leaflet. This was, effective in reducing the patient's moderate TR. We conclude that this procedure is a simple and reproducible method for repairing the tricuspid valve in Ebstein's anomaly, especially for cases with a large mobile anterior leaflet.
ABSTRACT
Chronic disseminated intravascular coagulation (DIC) complicates 5.7% of thoracic aortic aneurysm. DIC with thoracic aortic aneurysm is characterized by hyperfibrinolysis, but usually shows a stable condition in a state of compensated non-overt DIC with limited hemorrhagic symptoms. However, in some cases, hemorrhage caused by external factors may induce uncompensated overt DIC and lead to serious hemorrhagic tendencies. In the present study, we report a patient with a thoracic aortic aneurysm complicated by DIC who exhibited marked hemorrhagic tendencies. DIC remarkably improved following administration of recombinant human soluble thrombomodulin.
ABSTRACT
Infected aortic aneurysm is very difficult to treat and is associated with a high mortality rate. A 78-year-old man had been scheduled to undergo selective endovascular repair for distal aortic arch aneurysm. While standby, however, he was admitted to our emergency room because of hemoptysis. Rapid dilatation of the aneurysm shown on serial CT and elevated of inflammatory reactions yielded a diagnosis of infected aortic aneurysm. Because the aneurysm had ruptured into the left lung, emergency surgery was performed. Six days after the first operation, critical bleeding due to anastomotic disruption of the distal aorta caused by infection and subsequent cardiac arrest occurred. We immediately started open chest massage and controlled the bleeding manually in the ICU, while an operating room was prepared. In the redo operation, anastomotic disruption was repaired using the visceral pleura under deep hypothermic circulatory arrest. Anastomotic bleeding is a potentially life-threatening condition, therefore extremely prompt measures are vital. Appropriate management based on the assumption of anastomotic bleeding was very important in the postoperative course of this case of infectious aortic aneurysm.
ABSTRACT
Isolated unilateral absence of the right pulmonary artery without any intracardiac anomaly is a rare congenital cardiovascular disorder. We performed a successful surgical reconstruction with autologous tissue of this anomaly. The patient was a 1-month-old boy who had been transferred to our center at 3 days of age because of tachypnea and heart murmur. Multi-detector CT and radial angiography imaging revealed isolated unilateral absence of the right pulmonary artery and left patent ductus arteriosus. Conservative treatment did not help his progressive heart failure and pulmonary hypertension due to an acute increase of pulmonary blood flow. Therefore surgical correction was determined to avoid the worsening of those symptoms. Under cardiopulmonary bypass, the right pulmonary artery branching off from the brachiocephalic artery was removed and anastomosed to the main pulmonary artery with an autologous pericardium roll. Symptoms improved postoperatively and he was discharged in good condition on the 21st of postoperative day. Cardiac catheterization, 3 months later, showed excellent results.
ABSTRACT
A 23-year-old man had had a fever of unknown origin for a month. Aggravation of shortness of breath brought him to our hospital. After a close inspection, transthoracic and esophageal echocardiography (TEE) showed severe aortic valve regurgitation (AR) with vegetation extending for 25mm. The valve was bicuspid and the vegetation was on the left side valve. TEE also revealed a streak of mitral valve regurgitation (MR). In spite of continuous antibiotic therapy, congestive heart failure developed with progressive MR, so we performed an emergency operation. The aortic valve was bicuspid composed of an agglutinated left and non-coronary cusp, and 15×30mm vegetation was attached on the left. Checking the mitral valve after resection of aortic valve, we found a perforation 3mm in size at the center of the anterior mitral leaflet. After resection of the infected area, we repaired it with a Xenomedica patch 10mm in size through the aortic orifice. Two abscesses located beneath both leaflets were eradicated and finally aortic valve replacement was done with an SJM 23.
ABSTRACT
Perivalvular leakage (PVL) is one of the serious complications of mitral valve replacement. Between 1991 and 2006, 9 patients with mitral PVL underwent reoperation. All of them had severe hemolytic anemia before surgery. The serum lactate dehydrogenase (LDH) level decreased from 2,366±780 IU/<i>l</i> to 599±426 IU/<i>l</i> after surgery. The site of PVL was accurately defined in 7 patients by echocardiography. PVL occurred around the posterior annulus in 3 patients, anterior annulus in 2, anterolateral commissure in 1, and posteromedial commissure in 1. The most frequent cause of PVL was annular calcification in 5 patients. Infection was only noted in 1 patient. In 4 patients, the prosthesis was replaced, while the leak was repaired in 5 patients. There was one operative death, due to multiple organ failure, and 4 late deaths. The cause of late death was cerebral infarction in 1 patient, subarachnoid hemorrhage in 1, sudden death in 1, and congestive heart failure (due to persistent PVL) in 1. Reoperation for PVL due to extensive annular calcification is associated with a high mortality rate and high recurrence rate, making this procedure both challenging and frustrating for surgeons.
ABSTRACT
A study was conducted to evaluate the clinical and hemodynamic performance of the 19-mm Medtronic Mosaic Valve (MMV) in the aortic position, which is a third-generation stented porcine bioprosthesis. Between 2003 and 2006, 9 patients underwent AVR using the 19-mm MMV. None of the patients were suitable for a 19-mm Perimount bioprosthetic valve due to having a small annulus and sinotubular junction. The patients included 3 men and 6 women with a mean age of 73.2±4.97 years and mean body surface area of 1.35±0.11m<sup>2</sup>. Preoperatively, 8 patients were in New York Heart Association class II and 1 was in class III. The reason for surgery was aortic stenosis in 8 patients and aortic regurgitation due to infective endocarditis in 1 patient. Four patients had chronic renal failure and were on hemodialysis, while 1 patient had Crohn's disease. Concomitant coronary artery bypass grafting was performed in 3 patients, and tricuspid valve annuloplasty was done in 1 patient. The follow-up period was 12.0±7.71 months. No deaths occurred, but there was 1 cerebral infarction. Postoperatively, the peak pressure gradient decreased from 81.3±32.7 to 40.3±16.3mmHg (<i>p</i><0.01). The mean pressure gradient also decreased significantly from 48.8±11.6mmHg to 23.9±9.32mmHg (<i>p</i><0.01). Left ventricular end-diastolic diameter was 47.9±3.82mm preoperatively and 45.1±7.53mm postoperatively, showing no significant change. The left ventricular mass index also improved from 217.3±46.9 to 160±54.9g/m<sup>2</sup> (<i>p</i><0.05). The ejection fraction was 72.0±8.93% preoperatively and 67.6±6.37% postoperatively, showing no difference. Although the postoperative indexed effective orifice area (EOAI) was 0.90±0.11cm<sup>2</sup>/m<sup>2</sup>, mild patient-prosthesis mismatch (EOAI 0.77cm<sup>2</sup>/m<sup>2</sup>) was noted in 1 patient. In conclusion, the early clinical and hemodynamic performance of the 19-mm MMV in small elderly patients was acceptable.
ABSTRACT
This study was designed to evaluate the late changes of coronary bypass grafts in 60 patients who had undergone coronary bypass surgery and postoperative angiography in the period from 1994 to 1999. Angiography was performed at mean intervals of 84 months and a total of 134 grafts and 162 anastomoses were visualized. The Left internal thoracic artery and saphenous vein had a patency of 85% and 82%, there was not statistically significant. In this series, late graft function did not relate to the site of implantation, that was mainly due to excellent results of saphenous vein grafts. With increasing proximal stenosis severity (under 75% versus over 90%), there was an increase in patency rates and this relationship was statistically significant (<i>p</i>=0.0005). That was why about 20% of the grafts to moderately stenotic target vessels had occluded within 1 month after surgery. Ten patients among these 60 had cardiac symptoms, 6 were due to graft failure and the other 4 were due to new lesions in the right coronary artery. In the other 12 patients new coronary artery lesions without cardiac symptoms had been detected. Periodic coronary examinations should be recommended for the patients after surgery, regardless of the absence of symptoms.
ABSTRACT
Protein C (PC) deficiency is an inherited thrombotic disorder with a prevalence of 0.19% among the general population. PC deficiency is associated with an increased risk of thrombosis when other risk factors are present, such as trauma, surgery, or infection, and is an important cause of mechanical valve thrombosis. We performed tricuspid valve replacement with a 29mm Carpentier-Edwards Perimount valve in a 20-year-old man with PC deficiency. The patient had corrected transposition of the great vessels with severe tricuspid insufficiency, as well as a history of cerebral infarction. In the perioperative period, we used only heparin sodium as the anticoagulant. When we restarted administration of warfarin, changing over from heparin, transient increases of serum plasmin inhibitor-plasmin complex (PIC) and thrombin antithrombin complex (TAT) levels were observed. Despite an increased dose of heparin, an appropriate activated partial thromboplastin time (APTT) was not obtained. This suggested a hypercoagulatory state, but the postoperative course was uneventful. Management of perioperative anticoagulation, prevention of late thrombotic events, and prosthetic valve selection in this particular situation are discussed.
ABSTRACT
The patient was a 71-year-old man who had been treated for Parkinson's disease for 21 years. He was admitted because nocturnal dyspnea occurred several times. Echocardiography revealed congestive heart failure because of combined mitral and aortic regurgitation. Double valve replacement was planned. There was a risk of the occurrence of neuroleptic malignant syndrome (NMS) if his drugs for Parkinson's disease were stopped suddenly, so careful control of drug doses was required. Although the patient developed aggravation of his Parkinson's symptoms, careful observation and adjustment of medications prevented the occurrence of NMS.
ABSTRACT
We describe a case of postoperative aortic valve regurgitation (AR) after arterial awitch operation (ASO) successfully managed by the modified Konno procedure. A 4-year-old girl with complete transposition of the great arteries (TGA, Type II) had undergone the ASO (LeCompte maneuver) at 10 days of age. Because of progression of moderate AR 4 years after ASO, the modified Konno procedure with aortic valve replacement (SJM 21mm) was successfully performed. She remains in good clinical condition at the last follow-up at 5 years.
ABSTRACT
A 38-year-old woman was referred to our hospital for treatment of infective endocarditis associated with abscesses in the brain and the left lower limb. A causative organism had not been detected by serial blood cultures. Preoperative brain CT revealed mycotic aneurysms and echocardiography showed a mobile vegetation (8mm in size) on the anterior leaflet of the mitral valve. We performed resection of the vegetation together with a small triangle of the anterior leaflet, after which the margins of the defect were approximated. Then bilateral Kay procedures and reinforcement with autologous pericardium were done to obtain proper coaptation. The patient's fever, left lower limb pain, and intracerebral mycotic aneurysms resolved after surgery. The brain abscess also became smaller. Mitral valve plasty should sometimes be considered in the active phase of endocarditis, even in patients with cerebral complications and without congestive heart failure.
ABSTRACT
Pulmonary venous obstruction (PVO) after repair of total anomalous pulmonary venous connection remains a significant problem. Once it occurs, it not infrequently recurs. A 14-month-old boy with recurrent pulmonary venous obstruction after repair of mixed type total anomalous pulmonary venous connection was successfully treated by the method of sutureless <i>in situ</i> pericardial repair and anastomosis of the left pulmonary vein to the left atrial appendage. His postoperative course was uneventful. Cardiac catheterization at 2 years and 9 months after the re-redo operation showed successful relief of PVO with marked reduction of pulmonary hypertension. In addition, multidetector computed tomography (MDCT) performed 3 years and 1 month after the operation showed no pulmonary vein obstruction.
ABSTRACT
A 9-month-old boy who had been given a diagnosis of double outlet right ventricle (DORY), partial anomalous pulmonary venous return (PAPVR), ventricular septal defect (VSD), pulmonary hypertension (PH) and polysplenia with azygos connection, underwent pulmonary artery banding at the age of 6 months. At 2 months after surgery, a chest computed tomogram revealed a main pulmonary artery aneurysm and a main pulmonary artery-right pulmonary artery fistula caused by bacterial endocarditis due to a methicillin-resistant <i>Staphylococcus epidermidis</i>. We performed pulmonary arterioplasty and re-pulmonary artery banding for acute aggravation of cardiac insufficiency and obtained good results. This is an extremely rare case that was treated infectious pulmonary artery aneurysm and fistula after pulmonary artery banding.
ABSTRACT
A 6-month-old baby boy had undergone the Jatene procedure at 4 days. Four months later, catheter intervention (balloon angioplasty) was performed because of severe stenosis at the bifurcation of the pulmonary arteries. Twenty days later, several episodes of cyanosis occurred and he was readmitted. The existence of shunt flow between the sinus of valsalva and the pulmonary bifurcation was detected by echocardiography and examination by 16-row MDCT revealed 2 holes at this site. Under a diagnosis of aortopulmonary (AP) window, the patient was placed on cardiopulmonary bypass and the pulmonary artery was opened after aortic clamping. There was a ridge between the bifurcation of the pulmonary arteries. After removing it, 2 holes were visualized that resembled the findings on 16-row MDCT. These holes were closed with Xenomedica patches and the main pulmonary artery was also extended with a Xenomedica patch. AP window is a rare complication after balloon angioplasty for pulmonary stenosis, but we must take great care to prevent this complication.
ABSTRACT
Preoperative evaluation of cardiac anatomy is essential to determine the correct surgical procedure for congenital heart disease. Multi-detector row CT (MDCT) is a useful alternative imaging modality to cardiac catheterization and echocardiography. Sixteen patients (12 with total anomalous pulmonary venous return (TAPVR) and 4 with aortic arch anomalies) underwent 16-slice multi-detector row CT scanning. Three-dimensional reconstruction by MDCT was useful to determine the type of TAPVR and the presence of pulmonary venous obstruction (PVO) in TAPVR patients, as well as to detect postoperative PVO in patients who underwent intracardiac repair. In 2 patients who had asplenia associated with TAPVR III and I a, MDCT enabled an intra-atrial approach for TAPVR repair by precise preoperative determination of the relationship between the common PV chamber and single atrium. In patients with aortic arch anomalies, MDCT was useful to determine the type of anomaly, the presence of arch hypoplasia, and any associated rare vascular anomalies (including isolated subclavian artery, and the right-sided descending aorta with left aortic arch). In conclusion, MDCT provides reliable preoperative evaluation of pulmonary venous return and aortic arch anatomy, and therefore is extremely useful for surgical management of congenital heart disease.
ABSTRACT
We present a case of Marfan's syndrome with acute aortic dissection during the trimester of her pregnancy, who underwent a Bentall operation 2 days after emergency cesarean section. A 24-year-old woman during the 31st week of pregnancy visited our emergency room due to sudden onset of chest and back pain, though she had no abnormality until this event. Because of her tall height, spider fingers, positive wrist sign, visual disorder and scoliosis, she was given a diagnosis of Marfan's syndrome. Enhanced CT and cardiac ultrasonography revealed that she was suffering from acute aortic dissection with annulo-aortic ectasia. Since it was difficult for her to continue with her pregnancy, she underwent emergency cesarean section and gave birth to a male baby weighted 1, 706g. Although there was little likelifood of early thrombus formation in the false lumen or significant aortic regurgitation indicating an emergency operation, fear of massive bleeding from her uterus and the exfoliated surface of the placenta after cesarean section required an observation period of 2 days. We performed a Bentall operation successfully after careful sedation, ventilation and blood pressure control for 2 days.
ABSTRACT
A 56-year-old woman suffering from mitral stenosis had underwent PTMC (percutaneous transvenous mitral commissurotomy) at age 46. After she developed congestive heart failure, mitral valve replacement (MVR) with Carbomedics 29M and tricuspid annuloplasty (TAP) was carried out. Four hours after admission to the ICU, massive bleeding was noticed. Cardiopulmonary bypass was restarted in the operating room. Laceration and hematoma were found at the posterolateral wall of the left ventricle. Under cardiac arrest with removal of the prosthetic valve, an internal tear was detected about 2cm below the anterolateral commissure (Miller Type III). The tear was covered with a horse pericardial patch (2×3cm) using 6-0 running sutures with reinforcement with gelatin-resorcine-formaline (GRF) glue between the laceration and the patch. MVR sutures in the annulus above the ventricular tear were first passed through the annulus, the pericardial patch and then the prosthetic cuff. Additionally, an epicardial tear was covered and reinforced with the fibrin sheet, GRF glue and pericardial patch in turn. Cardiopulmonary bypass was weaned easily without bleeding. The patient was intentionally on respiratory support with sedation for 3 days. The subsequent postoperative course was uneventful.
ABSTRACT
Coronary artery fistula is an unusual congenital anomaly, particularly in association with coronary aneurysm. In the present case, a right coronary fistula leading to the right atrium was associated with a giant coronary aneurysm. There have only been 3 such cases reported in the literature. Since both the aneurysm and the fistula were completely thrombosed, no heart murmur was detected and the patient was initially diagnosed as having an intracardiac tumor by echocardiography.