[Double Patch Closure for Ruptured Sinus of Valsalva Aneurysm:Report of a Case].

A 53-year-old man visited a previous hospital because of dyspnea. He was transferred to our hospital with a diagnosis of a ruptured Valsalva aneurysm. At surgery, the tip of aneurysm originated from the right sinus of Valsalva had ruptured into the right ventricular outflow tract. A longitudinal incision was made in the main pulmonary artery, and the rupture site was closed with continuous suture. The first Hemashield patch was sewn to the tissue around the aneurysm in the right ventricular outlet septum. After that, the second Hemashield patch was fixed to the patch of the right ventricular outlet septum by horizontal mattress suture from the aorta. There has been no problem for more than five years after surgery.

[Mycotic Aneurysm of the Ulnar Artery Associated with Infective Endocarditis;Report of a Case].

A 19-year-old man, with a history of hospitalization for infective endocarditis associated with Streptococcus mitis/oralis 2 months before, was admitted to our hospital because of stomach ache and pulsatile mass on the left forearm. Computed tomography(CT) and ultrasonography revealed a thrombus in the superior mesenteric artery and an aneurysm of the left ulnar artery. As vegetation was noted on the anterior leaflet of the mitral valve, mitral valve replacement and ulnar artery aneurysmorrhaphy were performed. He was discharged 24 days after surgery without any complications. Although mycotic aneurysm is one of the complications of infective endocarditis, it is rarely formed in the ulnar artery. Moreover, mycotic aneurysm may develop even after inflammatory reaction has subsided. Thus, longterm observation of patients with infective endocarditis is necessary.

[Surgical Repair of Kommerell's Diverticulum with Right Sided Aortic Arch;Report of a Case].

A 54-year-old woman was referred for assessment of dysphagia and extrinsic compression of the esophagus detected by upper gastrointestinal endoscopy. Computed tomography revealed the rightsided aortic arch with mirror image branching and Kommerell's diverticulum. To relieve the esophageal compression, surgical intervention was indicated. Descending aortic replacement with a Dacron graft was performed through right thoracotomy under partial cardiopulmonary bypass. The patient was discharged without any complication, and her dysphagia disappeared.

[Clinical effects of tolvaptan for patients with stage 4-5 chronic kidney disease in cardiac surgery].

We report clinical effects of tolvaptan, a vasopressin V2 receptor antagonist, in cardiac surgery. Tolvaptan was administrated to 5 patients with non-dialysis dependent stage 4-5 chronic kidney disease (CKD) during an early postoperative stage. Tolvaptan increased urine output and improved respiratory function in all patients without causing hemodynamic deterioration. All patients were able to avoid initiating long-term hemodialysis during hospital stay. Tolvaptan was effective and safe after cardiac surgery for patients with severe CKD.

[Bilateral congenital coronary-pulmonary artery fistulas; report of a case].

Bilateral coronary-pulmonary artery fistulas are very rare. We report a case of a 68-year-old woman without any previous medical history, who presented to our hospital after slow onset of chest heaviness on exertion. Coronary computed tomography (CT) and angiography revealed 2 fistulas:one arising from the left anterior descending artery accompanied by an aneurysm and the other from the right coronary artery. We opened the trunk of the pulmonary artery under cardio-pulmonary bypass and cardiac arrest. We recognized the outflow of the shunt just above the right pulmonary cusp, which was closed from the outside. We also closed the aneurysm of the shunt. Neither the fistulas nor the aneurysm was recognized by postoperative CT. The chest symptom disappeared.

[Surgical treatment of coronary sinus orifice atresia; report of a case].

We report a case of a 69-year-old man with coronary sinus orifice atresia incidentally found during mitral and tricuspid valve operation in. Preoperatively, a patent left superior vena cava was noted. An abnormal opening of the coronary sinus was recognized in the inter-atrial septum of the left atrium near the postero-medial commissure of the mitral valve. The coronary sinus was absent in the right atrium. A coronary sinus was created by resecting the inter-atrial septum of the right atrium, and the abnormal opening of the coronary sinus at the left atrium was closed with an autologus pericardial patch. Tricuspid annuloplasty was performed with a 30 mm MC3 ring. Postoperative coronary sinus flow was confirmed normal by enhanced computed tomography (CT). Preoperative recognition of this rare disease is important, especially when the surgical candidate has a patent left superior vena cava.

Impact of transapical aortic cannulation for acute type A aortic dissection.

OBJECTIVE: Early and mid-term result of transapical aortic (TAA) cannulation technique was evaluated compared with femoral artery (FA) cannulation in Acute Type A Aortic Dissection(AAAD). METHODS: From January 2000 to October 2013, 80 consecutive patients with AAAD were underwent the ascending aortic replacement at Nagasaki Kouseikai Hospital. These patients were divided into two groups according to the cannulation site, FA cannulation (n = 34) and TAA cannulation (n = 46). Early and mid-term outcomes were compared between two groups. RESULT: Preoperative patient characteristics were almost comparable between groups. The time from skin incision to starting cardiopulmonary bypass (CPB) was significantly shorter in the TAA group (45 ± 16 vs 23 ± 5.1 min; P <0.001). There were no significant differences in post-operative cerebral infarction in two groups (17% versus 11%; P = NS). The operative mortality rate was 8.8% in FA group and 4.3% in TAA group (P = NS). During follow up (mean, 6.8 years), survival at 3 years and 5 years was 77.4% and 71.9% in TAA group and 76.3% and 73.8% in FA group, respectively. CONCLUSION: The postoperative morbidity and mortality between the two groups were almost the same. TAA cannulation for acute Type A aortic dissection is faster, easy and safe with acceptable early and mid-term outcome.

Left ventricular myxoma originating from the papillary muscle.

A rare case of left ventricular myxoma presenting embolization into the brachial artery is reported. The sessile tumor originated from the posteromedial papillary muscle and involved the chorda supporting the posterior mitral leaflet. Complete excision of the tumor with the posterior head of the posteromedial papillary muscle, with the chorda and with the posterior mitral leaflet necessitated valve replacement. The tumor was well visualized by the superior-septal and transaortic approaches. These enabled exploration of all four cardiac chambers so as not to overlook any multifocal myxoma. The left ventricular myxoma should be completely resected with the surrounding endocardium in order to avoid recurrence of the disease.

[Valvuloplasty for aortic regurgitation with bicuspid valve: report of a case].

A 32-year-old male patient with bicuspid aortic valve underwent valvuloplasty for the treatment of aortic regurgitation. The aortic regurgitation was estimated to be grade III based on the transthoracic echocardiography and aortography findings. Transesophageal echocardiography showed prolapse of the conjoined leaflet. At surgery, the valvuloplasty consisted of triangular resection and re-suture of the prolapsed larger leaflet, and subcommissural annuloplasty. The degree of the aortic regurgitation decreased to very slight degree after the repair. The peak pressure gradient across the repaired aortic valve was 8.8 mmHg. The patient was discharged without any complications. The bicuspid aortic valve demonstrating aortic regurgitation seems to be repairable. As a result, the valvuloplasty is indicated for such patients, especially for young patients.

Aortic valve replacement with smaller valve size.

The occurrence of prosthesis-patient mismatch after aortic valve replacement with a small valve size was evaluated in 249 patients, focusing on echocardiographic data. Aortic valve pathology included regurgitation in 174 patients and stenosis in 75. Echocardiography was performed in the early and late postoperative periods. A projected effective orifice area index < 0.85 cm(2)·m(-2) was noted in 56 patients; values ≥ 0.85 cm(2)·m(-2) were found in 128. Postoperative changes in ejection fraction, left ventricular mass regression, and peak transprosthetic gradient were similar in both groups. Small prostheses (≤ 19 mm) were used in 43 patients who had significantly higher postoperative transprosthetic gradients in both the early and late periods, compared to those with larger prostheses. Our findings show that the occurrence of prosthesis-patient mismatch after aortic valve replacement is rare. Left ventricular mass regression occurred in most patients, with acceptable transprosthetic gradients.

Predischarge angiographical evaluation of radial artery graft harvested by endoscopic harvesting system.

OBJECTIVE: Endoscopic radial artery harvesting (ERAH) has superior cosmetic advantages over conventional harvesting methods. With instrumental advancements, these techniques have become easier to adopt and require less time to learn. In most reported cases, the quality of harvested conduits is discussed based on macroscopic and histologic examinations and clinical outcomes. However, predischarge angiography gives a straightforward answer regarding quality of harvested conduit. The aim of this study is to assess the quality of endoscopically harvested radial artery by predischarge angiographic evaluation. METHODS: Endoscopic procedure using VasoView 4 system was performed in 87 patients between September 2004 and December 2007, and 78 predischarge angiographical evaluations were completed and reviewed. Mean age of the patients was 66 ± 10 years and 18% were women. After ERAH was performed, accompanying veins were dissected by ultrasound scalpel. All conduits were as aortocoronary bypass under cardiopulmonary bypass. RESULTS: Mean arm ischemic time was 32 ± 13 minutes and length of harvested conduit was 17.8 ± 1.3 cm. Predischarge angiography demonstrated two occlusions at the proximal anastomosis in the 51st and 71st cases, although intraoperative flow study showed normal flow patterns in both cases. Stenosis in the conduits was observed in the first, sixth, and seventh cases. No further angiographical problems were found in the remaining conduits. CONCLUSIONS: Based on the angiographical results, problems with the harvested conduits occurred only in initial period. ERAH with VasoView system provides satisfactory angiographical quality after initial learning curve.

Early tracheal extubation after on-pump coronary artery bypass grafting.

OBJECTIVE: A fast-track recovery in cardiac surgery yields many benefits, and early tracheal extubation is important as the first step. The purpose of this study is to evaluate the status of early tracheal extubation after on-pump coronary artery bypass grafting (CABG) and to find key factors for successful early tracheal extubation. METHODS: From September 1996 to February 2005, isolated on-pump CABG was performed on 485 patients, and an early tracheal extubation protocol was employed on all. It was defined as tracheal extubation within 6 hr of arrival in the intensive care unit (ICU). RESULTS: An early tracheal extubation was successful on 450 patients (92.5%). Reintubation was necessary in 5 (1.1%) because of a resternotomy for bleeding in 3 and ventricular arrhythmia in 2. Mechanical ventilation exceeding 24 hours was required in 7 patients (1.4%) because of heart failure in 4 and respiratory failure in 3. Significant factors of successful early tracheal extubation were the European System for Cardiac Operative Risk Evaluation (P <0.05), the number of diseased arteries (P <0.01), ejection fraction (P <0.05), operation time (P <0.01), blood transfusion in ICU (P <0.05), and drainage in the first 12 hr (P <0.05). CONCLUSIONS: Early tracheal extubation can be successfully performed in most patients receiving on-pump CABG. The management of higher-risk patients and efforts to reduce operation time and blood loss are keys to success for early tracheal extubation.

Hemostatic effectiveness of a new application method for fibrin glue, the "rub-and-spray method", in emergency aortic surgery for acute aortic dissection.

PURPOSE: This study was performed to evaluate the clinical hemostatic effectiveness of a new application method for fibrin glue, the rub-and-spray method, in aortic surgery. METHODS: Twenty consecutive patients undergoing emergency ascending aorta or ascending-hemiarch replacement for Stanford type A acute aortic dissection were prospectively randomized into 2 groups, one with the rub-and-spray method (group G, 10 patients) and one without fibrin glue (group C, 10 patients). The rub-and-spray method consists of using a finger to rub the fibrinogen solution over needle holes, then spraying the fibrinogen solution and the thrombin solution simultaneously over the anastomosis, using an application nozzle. The number of bleeding needle holes at the proximal and distal anastomoses just after reperfusion, the hemostatic period (time from administration of protamine sulfate until closure of the pericardium), and the amounts of blood losses during this hemostatic period were measured. RESULTS: The values in group G and group C were as follows: proximal needle holes (26.8 +/- 1.5, 26.4 +/- 2.4, p = 0.466); proximal bleeding needle holes (0.2 +/- 0.4, 19.3 +/- 3.5, p <0.001); distal needle holes (28.7 +/- 2.5, 27.8 +/- 4.4, p = 0.675); distal bleeding needle holes (1.3 +/- 1.2, 19.9 +/- 5.0, p <0.001); estimated bleeding proportion of the proximal needle holes (0.7 +/- 1.6%, 73.8 +/- 16.0%, p <0.001); estimated bleeding proportion of the distal needle holes (4.4 +/- 3.7%, 71.9 +/- 15.7%, p <0.001); estimated median hemostatic period (41.5 min [32-49], 51 min [44-89], p = 0.036); amounts of blood losses during this hemostatic period (99 +/- 76 ml, 257 +/- 163 ml, p = 0.016). The number of bleeding needle holes, the bleeding proportion of the proximal and distal needle holes, the hemostatic period, and the amounts of bleeding during this hemostatic period were significantly less in group G. CONCLUSION: This new application method for fibrin glue, the rub-and-spray method, revealed significant hemostatic effectiveness, even in hemostatically difficult surgery of acute aortic dissection that requires systemic heparinization and prolonged cardiopulmonary bypass with deep hypothermia.

Surgical strategy for impending rupture of an infected anastomotic pseudoaneurysm of the aorta 9 years after a Bentall procedure: radical surgery involving en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft.

Infection of the sternum and anterior mediastinitis after open heart surgery are serious complications that are intractable with high case fatality rates. Frequently, infection spreads to an artificial foreign body in the mediastinum, causing difficulties with treatment. We report a case of infected pseudoaneurysm of the aorta at the anastomotic site of the artificial vascular graft. The infection spread from sternal osteomyelitis 9 years 5 months after aortic root replacement (Bentall procedure) for acute aortic dissection. We performed radical surgery that included en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft, with successful results. We report here the surgical strategy including the approach.

Dual left anterior descending coronary artery: report of a case.

We report a case of Type I dual left anterior descending artery (LAD) successfully treated by coronary artery bypass grafting including the long LAD. This rare coronary artery anomaly is of clinical importance in the field of myocardial revascularization.