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<p>We encountered a case of ruptured sinus of Valsalva aneurysm caused by an unusual event. A 38-year-old-man was referred to our hospital owing to cough and orthopnea after being struck in the chest while playing baseball. Echocardiography showed a ruptured right sinus of Valsalva aneurysm and ventricular septal defect (VSD). Intraoperative findings revealed rupture of the sinus of Valsalva aneurysm into the right ventricle, with a typical “windsock” appearance. The fistula and VSD were closed with Dacron patches at both the right coronary cusp and right ventricular outflow tract. The patient was discharged on the 11th postoperative day without any complications.</p>
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Adequate exposure is crucial for successful mitral valve surgery. We report simple techniques for optimizing mitral valve exposure via conventional left atriotomy. The right side of the pericardium is sutured to the chest wall after medial sternotomy and pericardiotomy. We mobilize both the superior and inferior vena cava by dissecting the pericardium on their right side. Tourniquets are placed around both venae cavae and hitched up to the left after bicaval cannulation. Then the right side of the left atrium is lifted up and exposed. A longitudinal incision of the left atrium allows excellent exposure of the mitral valve using a single retractor. We adopted these procedures for 38 consecutive patients for mitral valve plasty, and additional incisions were not required. Simple mitral plasty procedure in 18 cases required 212±32 min for operation, 120±22 min for extracorporeal circulation and 88±18 min for aortic cross clamp. We conclude that this method is simple and does not lengthen the procedure.
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We describe an unusual case of a chronic pulmonary thromboembolism with right atrial thrombus. A 56-year-old man suffering from chronic pulmonary thromboembolism for 5 years complained of increasing dyspnea. Computed tomography revealed massive emboli in bilateral pulmonary arteries and a thrombus in the right atrium. Massive tricuspid regurgitation and atrial fibrillation were also recognized. We performed pulmonary thromboendarterectomy using a Jamieson rigid long miniature sucker with a rounded tip and our original flexible sucker under deep hypothermic circulatory arrest. Right atrial thrombectomy, tricuspid annuloplasty and a Maze procedure were also performed during the cooling, recirculating, and warming period. His postoperative cause was uneventful, and he was able to return to an ordinary lifestyle without acquiring oxygen inhalation. Tricuspid annuloplasty and Maze operation during pulmonary thromboendarterectomy contributed to the maintenance of stable homodynamics during and after surgery.
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Isolated cleft of the anterior mitral leaflet in the presence of an intact atrioventricular septum is a rare cause of mitral regurgitation. We report a surgical case with cleft of the anterior mitral leaflet and abnormality of papillary muscles. A 53-year-old man was admitted to our hospital because of congestive heart failure. Echocardiography showed severe mitral regurgitation, severe tricuspid regurgitation, abnormal direct connection of the anterolateral papillary muscle and the anterior mitral leaflet and adhesion of the base of papillary muscles. At the posterior portion of the anterior leaflet, a 1-cm cleft was found during surgery. The top of the anterolateral papillary muscle adhered to the anterior leaflet, but rheumatic changes were not noted. The cleft was sutured directly, and annuloplasty was performed with a 31-mm Duran flexible ring. Tricuspid annuloplasty was also performed with the DeVega method. His postoperative course was not eventful. Mitral regurgitation caused by mitral cleft associated with abnormal connection of papillary muscles and the mitral leaflet have not been previously reported.
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An 81-year-old man complaining of back pain was admitted. Computed tomographic scan revealed an aortic arch aneurysm and an abnormal retroesophageal artery. It was believed to be an aberrant right subclavian artery. The diagnosis was confirmed by angiogram. Although there was no evidence of rupture, his back pain prompted us to perform emergency surgery. Through median sternotomy using a cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion, total arch replacement was done. There was evidence of impending rupture, which was probably the cause of his back pain. The proximal portion of the aberrant right subclavian artery was severely calcified, so the right subclavian artery was reconstructed. It was anastomosed with one branch of the arch graft which passed the anterior of the trachea. The postoperative course was uneventful. We believe median sternotomy was a proper approach for such a situation.
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A 74-year-old woman presented with a pulsatile mass and pain in the right mid-thigh. Angiography demonstrated a ruptured solitary aneurysm at the superficial femoral artery (SFA), 45mm in diameter. The operation consisted of replacement of the aneurysm with a saphenous vein bypass grafting to the SFA. The pathological examination of the resected arterial wall revealed degenerative changes due to cystic medial necrosis. In the literature, there has been no report, as far as we know, on true aneurysm of the superficial femoral artery caused by cystic medial necrosis. Therefore, it is considered that our case is a very rare presentation of aneurysm with this particular etiology which occurred in the peripheral artery of a lower extremity.
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In this report, we describe our surgical experience with seven cases of acute type A aortic dissection which resulted from retrograde propagation from tears in the proximal descending arota. As an emergency procedure, we used a ringed intraluminal prosthesis in six patients and five of these survived. All survivors underwent follow up CT scanning during a period ranging from 4 months to 5.6 years after surgery, especially to evaluate the fate of the false lumen on the residual aorta. In four patients, the arch dissection has been completely occluded by thrombosis, however, it remained patent in one patient 2.3 years postoperatively in whom reentry was found in the arch vessel at the time of operation. Enlargement of the false lumen beyond the descending aorta was found in two patients. On the other hand, the results have been excellent in the most recent patient who underwent complete graft replacement of both the ascending aorta and aortic arch including the primary tear. The authors believe, therefore, that the complete graft replacement of the ascending aorta to the aortic arch should be considered as the procedure of choice in these particular patients. Only such procedures enable the complete healing of both the ascending and arch dissection, and reoperation can be confined to the area distal to the descending aorta, if necessary.
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Two patients of chronic mediastinitis after cardiac surgery were treated by omental transfer. Their previous cardiac operations were open mitral commissurotomy and aortic valve replacement. They underwent radical surgical therapy for mediastinitis 8 to 9 years after the first cardiac surgery. In both cases, the infection resulted from Dacron felt on the ascending aorta. Under the cardiopulmonary bypass, the Dacron felt and infected tissue were resected. And omental transfer was done to prevent recurrent infection. The patients have been follwed up for 10 to 14 months. And they have no symptoms of their mediastinitis during these periods. From these experience, we consider that omental transfer is very helpful to treat infectious complications after cardiac surgery.
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From January, 1975 to December, 1989, 231 Björk-Shiley prostheses have been implanted in our hospital. During this period, we have experienced thrombosed valves in 0.69%/pt-yr for the aortic and 1.2%/pt-yr for the mitral position. Ten patients, four in the aortic and six in the mitral, have had thrombotic obstruction of a prosthetic valve. Seven cases of them had insufficient warfarin control. Clinical signs of thrombosed valves were dyspnea, thromboembolism and abnormal cardiac sound. Cineradiography was the most useful diagnostic method. Two cases underwent thrombolytic therapy, but one case died of cerebral complication and another needed an emergency cardiac operation 24 hours after the onset. Six survived among the eight surgical cases. We concluded that thrombosed valves mainly resulted from an insufficient anticoagulant therapy and an urgent surgical intervention would better be performed.