Aortic valve area index values of Trifecta implants correlate with energy loss and increased valve stress.

Biological valves are becoming more frequently used in aortic valve replacement. While several reports have evaluated the performance of biological valves, echocardiography studies during exercise stress remain scarce. Furthermore, no current reports compare rate changes in the aortic valve area of biological valves under increased exercise load. Here, we performed exercise stress echocardiography in patients after AVR with Trifecta or Inspiris valves and compared the rates of change in aortic valve areas (AVA). In addition, hydrodynamic analysis at rest was conducted with four-dimensional flow magnetic resonance imaging (4D-flow MRI). Exercise stress echocardiography was performed in seven Trifecta and seven Inspiris patients who underwent AVR at our hospital while 4D flow MRI was performed in all but two Trifecta cases. Comparing the percentage change in AVA when loaded to 25 W versus at rest, Trifecta was greater than Inspiris (28.7 ± 36.0 vs - 0.8 ± 12.4%). The smaller AVA at rest was considered causative for this. Meanwhile, Trifecta systolic energy loss in the prosthetic valve segment on 4D-flow MRI (97.5 ± 35.9 vs 52.7 ± 25.3 mW) was higher than Inspiris. The opening of the Trifecta valve was considered to be restricted at rest and this may reflect the current reports of early valve degradation requiring reoperation. Taken together, we observed that the Trifecta design may promote faster wear due to higher valve stress.

[Giant Thrombus in the Left Atrium Showing a Rapid Growth:Report of a Case].

A 74-year-old woman had been on hemodialysis for about 2 months using a short-term indwelling dialysis catheter due to chronic kidney disease. A 20 mm-diameter left atrial neoplastic lesion was noted during a screening echocardiogram performed at the time of induction of hemodialysis. The lesion rapidly increased to 30 mm 2 months later and was referred to our hospital for surgical resection. Under cardiopulmonary bypass and cardiac arrest, tumor resection was performed. Although the lesion was myxomatous with a thin stalk on the left atrial ceiling, the pathological diagnosis was thrombus. After the initiation of anticoagulation, the patient was discharged.

[Staged Hybrid Repair Including Abdominal Branches Bypass Grafting for Crawford Typeâ ¡ Thoracoabdominal Aortic Aneurysm:Report of a Case].

A 64-year-old female with a diagnosis of Crawford typeⅡ thoracoabdominal aortic aneurysm( TAAA) including enlargement of the ascending aorta underwent a staged hybrid repair including visceral artery debranching thoracic endovascular aortic repair( TEVAR). First, total arch replacement with elephant trunk method was performed, followed by TEVAR for the descending thoracic aorta, and finally visceral artery debranching TEVAR for the thoracoabdominal aorta. Complications such as spinal cord infarction did not occur throughout the procedure. Surgical repair of Crawford typeⅡ TAAA involves a wide range of treatment and is highly invasive, requiring ingenuity in terms of preventing complications such as spinal cord infarction. Hybrid repair including visceral artery debranching TEVAR may be an effective treatment modality for complex aortic lesions including TAAA, but requires careful follow-up including remote complications.

[Requiring Differential Diagnosis of Pulmonary Arteriovenous Fistula and Pulmonary Venous Aneurysm: Report of a Case].

A pulmonary arteriovenous fistula (PAVF) is a direct abnormal connection between the pulmonary artery and pulmonary vein, lacking capillary tissue. On the other hand, a pulmonary venous aneurysm (PVA) is a localized dilation and aneurysmal formation in the pulmonary vein without reflux issues. Treatment approaches for PAVF and PVA differ, considering surgery or catheter embolization for PAVF due to the risk of cerebral infarction or rupture caused by the abnormal shunt. PVA cases, being rare in rupture and embolism, are usually recommended for observation. Therefore, distinguishing between these two conditions is crucial. This article presents a case where both PVA and PAVF were present, necessitating a differential diagnosis.

[Total Arch Replacement using the Frozen Elephant Trunk for Kommerell Diverticulum with Right Aortic Arch:Report of a Case].

A 42-year-old woman with dysphagia was referred to our hospital. Computed tomography (CT) revealed Kommerell diverticulum( KD) associated with right aortic arch( RAA) and aberrant left subclavian artery (ALSCA). We performed total arch replacement (TAR) using a frozen elephant trunk (FET) technique. We ligated ALSCA at the distal portion of the KD after perfusing from a 8 mm tubular graft from left axillar artery. We inserted a FET from the ascending aorta to avoid locating the nonstented portion at the steep-angled site of RAA. Postoperatively dysphagia disappeared and CT scan showed complete exclusion of KD without leakage of the stent graft and successful reconstruction of the arch. The TAR and FET technique is an effective procedure for KD with RAA and ALSCA.

[Comparison of Three Methods of Sternal Closure after Open Heart Surgery:Analysis of 722 Cases for 11 Years].

722 patients who returned to the intensive care unit( ICU) after completing the cardiac surgery and closing the median sternotomy from Jan 2010 to Feb 2021 at our hospital were divided into 3 groups according to the different sternal closures. Sternum was fixed with 6 wires alone in group A (n=333), with 2 absorbable plates and 6 wires in group B( n=259) or with 3 titanium plates with 20 screws and 4 wires in group C (n=130). Background characteristics were not different between the 3 groups. Total number of 3 complications (postsurgical bleeding, mediastinitis and delayed cardiac tamponade) was significantly less in group B and C than group A. Among them postsurgical bleeding needed hemostasis surgery was significantly less in group C than in group A. Surgical nor hospital mortality were not significantly different in 3 groups. Postsurgical complications were significantly less when the sternum closure was fixed with plates( absorbable, not absorbable).

Hybrid surgical and endovascular repair for anastomotic pseudoaneurysms after total arch replacement.

An 83-year-old woman who had undergone total arch replacement for a thoracic aortic aneurysm seven years prior experienced concurrent rupture of second and third branch anastomotic pseudoaneurysms. A stent graft was initially deployed across the pseudoaneurysm from the third branch to the left subclavian artery. Following the left axillary and left carotid arterial bypass, the origin of the second branch was embolized with metallic coils. As a result, both anastomotic pseudoaneurysms were undetectable by both completion angiogram and postoperative CT. By combining surgical and endovascular procedures, ruptured anastomotic pseudoaneurysms after total arch replacement can be repaired without a risky resternotomy.

Surgical extraction of a giant intracardiac lead vegetation and epicardial pacemaker reimplantation in a pacemaker-dependent hemodialysis patient.

A 57-year old male with a dual-chamber pacemaker and 40-year history of hemodialysis and autoinflammatory disease developed a large, 35 × 35 mm intracardiac vegetation on the right ventricular pacing lead. As this mass was large enough to occlude the tricuspid valve orifice, transvenous lead extraction was deemed unsuitable. Instead, an urgent surgical extraction of the whole pacemaker system, including leads and vegetation, was conducted under cardiopulmonary bypass. In light of a high risk of recurrent blood infection, a new dual-chamber pacing system was then immediately re-established using epicardial pacing leads on the right atrium and ventricle instead of transvenous electrodes. This case of a rare, giant intracardiac lead vegetation lacked most known causal factors, except for renal failure, but a possibly immunosuppressed cardiac microenvironment due to long-term steroid therapy may have been an important influencing factor.

[Surgical Treatment of Prosthetic Valve Endocarditis].

Between 2003 and 2014, at Jichi Medical University Hospital, 11 patients with prosthetic valve endocarditis (PVE) underwent re-operation. There was 1 in-hospital death and 2 late deaths. The cause of death was cirrhosis, heart failure and sepsis, respectively. Emergency surgery, previous double valve replacement (DVR) and Staphylococcus infection were common risk factors for all 3 cases. Two cases of patients that survived who underwent mitral valve replacement (MVR) and DVR for PVE after DVR were treated with multiple antibiotic courses for bacteremia associated with hemodialysis and colon cancer. One patient who underwent DVR after mitral valve plasty which was complicated with cerebral hemorrhage, had survived and was discharged. Of the aortic PVE patients, 2 cases of aortic valve replacement (AVR) using a mechanical valve, 1 case of aortic root replacement (ARR) using a mechanical valve, and 1 ARR using the homograft, were considered cured and never relapsed. A patient with aortic PVE, who underwent AVR after cesarean section for heart failure in birth period, has received ARR twice with the mechanical valve for recurrent pseudo-aneurysm of the left ventricular outflow tract. Since hemodialysis and colon cancer is a risk factor for recurrent PVE, it is necessary to consider the long-term administration of antibiotics after surgery.

[Reoperative off-pump coronary revascularization via left thoracotomy using the PAS-Port system to the descending thoracic aorta: report of a case].

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.

[Mitral valve repair for active infectious endocarditis].

Between December 2005 and November 2011, 11 patients with mitral valve regurgitation (MVR) resulting from native valve endocarditis underwent mitral valve plasty (MVP). These patients were aged 44.4 ± 11.3 years. The mean follow-up period of the patients was 3.1 ± 0.63 years. Five patients were men. Emergency or urgent surgery was required in 5 patients. Three patients were categorized as New York Heart Association( NYHA) functional class IV. Infection of the mitral valve, occurred in the anterior leaflet in 3 patients, the posterior leaflet in 5 patients, and the anterior-posterior leaflet in 3 patients. Nine patients had a resection suture technique. One patient had chordae replacement with expanded polytetrafluoroethylene (ePTFE), and 1 patient had replacement using the pericardium. All patients received ring annuloplasty with a partial flexible ring. After surgery, all patients were categorized as NYHA functional class I. There were no valve associated complications, no hospital deaths, no late deaths, and no reoperations. We conclude that MVP is an effective treatment for active infective endocarditis( AIE) with mitral regurgitation.

Two cases of catastrophic deterioration and multiple leaflet detachment in Trifecta valves.

Reports of early and catastrophic acute structural valve deterioration (SVD) in Trifecta valve (Abbott, St Paul, MN, USA) with multiple leaflet detachment are rare. We encountered two cases of early SVD in Trifecta valve with tears on two leaflets. Both cases presented with acute heart failure because of aortic insufficiency, and underwent redo aortic valve replacement; one patient died due to multiple organ failure caused by cardiogenic shock. Durability issues with the Trifecta valves; thus, necessitates long-term vigilance in aortic replacement patients.

[Emergency stent placement after descending aortic replacement with chronic aortic dissection].

A 49-year-old man with asymptomatic chronic aneurysmal dissection was admitted to our hospital. He had undergone ascending aortic replacement for type A aortic dissection 7 months before. We performed descending aortic replacement for chronic aneurysmal dissection. Renal dysfunction appeared 1 day after the operation. Contrast-enhanced computed tomography indicated that the true lumen was severely compressed by a false lumen, and that the origins of the renal artery were occluded. We performed emergency endovascular stent placement to dilate the true lumen. Immediately after this procedure, renal ischemia improved. The postoperative course was uneventful. An endovascular approach using bare stent can be a treatment option that is less invasive and prompter for a patient with renal ischemia resulting from aortic dissection.

Simultaneously performed mitral valve replacement and Hartmann's operation for infectious endocarditis from Streptococcus bovis and rectal cancer.

In patients with surgical indications for both cardiac surgery and a malignant neoplasm, cardiac surgery should generally be performed first; however, in some cases simultaneous surgery is recommended. We report a case of infectious endocarditis of the mitral valve caused by Streptococcus bovis with rectal cancer. Blood cultures showed a rise in coagulase-negative S. bovis, and the source of infection was thought to be the rectal cancer. The patient presented with cerebral infarction prior to surgery, and the possibility of recurrence of an infarction was predicted. The tumor of the rectum was hemorrhagic, so to avoid hemorrhagic complications due to perioperative heparinization and anticoagulant therapy and to remove the source of infection, mitral valve replacement and a Hartmann's operation were performed simultaneously. The postoperative course was uneventful.

Bioprosthetic aortic valve replacement 12 years after percutaneous aortic valvuloplasty in a young female adult with hope of pregnancy.

CASE: A 26-year-old woman who had congenital aortic valve stenosis presented with exertional dyspnea. She had undergone percutaneous balloon aortic valvuloplasty 12 years previously at the age of 14. When she was 20 years old, she delivered a neonate by elective cesarean section at the 31st week of gestation because the mean pressure between the left ventricle and the ascending aorta was 52 mmHg. OUTCOME: She successfully underwent aortic valve replacement with a bioprosthetic valve combined with replacement of the ascending aorta in order to make the next pregnancy possible. CONCLUSION: The long-term prognosis of percutaneous balloon aortic valvuloplasty might be acceptable for some patients, even though this procedure is associated with the possibility of secondary interventions.

Unique nonstructural dysfunction of the omnicarbon valve: case report.

BACKGROUND: Pannus formation may disturb the leaflet movement of the prosthetic valve. CASE PRESENTATION: A 61-year-old woman presented with exertional dyspnea. She had undergone mitral valve replacement with a bioprosthetic valve 31 years ago, which was replaced with a tilting disc valve 22 years ago. The present laboratory findings revealed hemolytic anemia. Echocardiography showed an increased mean pressure gradient through the mitral valve and moderate to severe regurgitation around the minor orifice of the tilting disc valve. She therefore underwent a third operation. Pannus formation was found on the prosthetic valve ring, but it did not obliterate the prosthetic valve orifice. After removing the valve, the posterior wall of the left ventricle was seen to be associated with thickened endocardium. A bileaflet valve was implanted. Postoperative echocardiography showed that the implanted valve functioned well. CONCLUSIONS: Nonstructural dysfunction of the mechanical heart valve might occur long after operation. These changes are particularly observed with a tilting disc valve.

Anatomical repair of partially unroofed coronary sinus syndrome through the coronary sinus orifice.

A 15-year-old girl was admitted for repair of partially unroofed coronary sinus syndrome. A preoperative echocardiographic study disclosed the dilated coronary sinus and a draining blood flow into the right atrium from both the left atrium and the end of the coronary sinus. At surgery, the distal portion of the coronary sinus roof was found to be absent. The defect was repaired through the coronary sinus orifice with a patch. No electrophysiological conduction abnormalities developed and follow-up echocardiography showed neither residual shunts nor coronary sinus blood flow disturbances.

Clinical features of third open-heart valve surgery at the same valve position.

OBJECTIVE: Recently, there has been an increase in case of repeated open-heart valve surgery and the clinical results of the second surgery are only slightly worse than those of the first surgery. However, clinical results of the third open-heart valve surgery at the same position are rarely reported. Clinical features of third open-heart valve surgery at the same position are discussed in this study. METHODS: Between 1995 and 2004, 16 patients underwent third open-heart valve surgery at the same valve position under cardiopulmonary bypass. The average age of the 16 patients, 12 females and 4 males, was 56 +/- 15 years. Clinical features of the 16 cases were retrospectively analyzed. RESULTS: Mechanical valve nonstructural dysfunction was the most common valve malady, followed by bioprosthetic valve dysfunction. The duration of surgery from skin incision to establishment of the cardiopulmonary bypass was 94 +/- 42 minutes. Myocardial ischemia time was 137 +/- 38 minutes and extracorporeal circulation time was 212 +/- 82 minutes. Early mortality was seen in 1 patient (6.25%) and late mortality was seen in 1 patient. CONCLUSION: Mechanical valve nonstructural valve dysfunction leads to repeated valve surgery. The clinical results of the third open-heart valve surgery at the same valve position are acceptable, and the mid-term survival is excellent.

Effects of nafamostat mesilate and minimal-dose aprotinin on blood-foreign surface interactions in cardiopulmonary bypass.

BACKGROUND: The pharmacological inhibition of blood-foreign surface interactions is an attractive strategy for reducing the morbidity associated with cardiopulmonary bypass. We compared the inhibitory effects of nafamostat mesilate (a broad-spectrum synthetic protease inhibitor) and minimal-dose aprotinin on blood-surface interactions in clinical cardiopulmonary bypass. METHODS: Eighteen patients undergoing coronary surgery were divided into three groups: (1) the control group (heparin, 4 mg/kg; n = 6), (2) the nafamostat mesilate group (heparin plus nafamostat, 0.2 mg/kg bolus followed by 2.0 mg/kg/h during cardiopulmonary bypass; n = 6), and (3) the aprotinin group (heparin plus aprotinin, 2.0 x 10(4) KIU/kg; n = 6). Platelet count, platelet aggregation, beta-thromboglobulin, prothrombin fragment F1.2, thrombin-antithrombin complex, plasminogen activator inhibitor-1, alpha2-plasmin inhibitor-plasmin complex, D-dimer, neutrophil elastase, and interleukin-6 were measured before, during, and after bypass. Bleeding times and blood loss were recorded. RESULTS: There were no significant differences between groups in platelet count, beta-thromboglobulin, plasminogen activator inhibitor-1, interleukin-6, bleeding times, or blood loss. Platelet aggregation was better preserved at 12 hours after surgery in the nafamostat and aprotinin groups than in the control group. Prothrombin fragment F1.2, thrombin-antithrombin complex and neutrophil elastase levels were significantly reduced by aprotinin, but not by nafamostat as compared with the control group. The alpha2-plasmin inhibitor-plasmin complex and D-dimer were significantly lower with either of the drugs. Aprotinin showed better control of D-dimer than did nafamostat. CONCLUSIONS: Nafamostat mesilate fails to reduce thrombin formation and neutrophil elastase release, whereas minimal-dose aprotinin inhibits both. Neither nafamostat nor aprotinin inhibits platelet activation. Nafamostat reduces fibrinolysis during cardiopulmonary bypass, although its effect is not as potent as aprotinin.

Twenty-two year experience with the omniscience prosthetic heart valve.

This study was designed to evaluate the long-term clinical results of the Omniscience tilting disc valve. Omniscience valves were implanted in 51 patients (mean age, 50 +/- 10 years); 18 had aortic valve, 24 had mitral valve, and 9 had both aortic and mitral valve replacements. Oral warfarin potassium and dipyridamole were prescribed as our anticoagulant therapy. Preoperatively, 42 patients were in New York Heart Association class III or IV, and 23 of 25 surviving patients were in class I or II after operation. There were 2 (3.9%) early deaths and 23 late deaths (3.5 +/- 0.7% per patient-year). Cardiac related mortality including congestive heart failure, sudden death, and thromboembolism, and hemorrhagic complications were seen in 16 patients. Overall survival at 10, 15, and 20 years was 77 +/- 6%, 62 +/- 7%, and 46 +/- 7%, respectively. Thromboembolic complications were seen in 5 patients, for a rate of 0.8 +/- 0.3% per patient-year; similarly, hemorrhagic complications were also seen in 5 patients. Nonstructural prosthetic valve dysfunction was seen in 4 patients, for a rate of 0.6 +/- 0.3% per patient-year, and sudden death was seen in 2, a rate of 0.3 +/- 0.2% per patient-year. The Omniscience prosthesis demonstrated excellent postoperative clinical status with low rates of valve related complications.