[Redo Mitral Valve Replacement for Prosthetic Valve Endocarditis in a Patient with End Stage Colon Cancer:Report of a Case].

Prosthetic valve endocarditis (PVE) is rare but devastating. A 69-year old man admitted for active endocarditis caused by Streptococcus pasteurianus. Antibiotic therapy was started, but the patient developed bowel obstruction owing to cancer with multiple liver metastases, and underwent transverse colectomy. Following colectomy, antibiotic agent was given continued for 4 weeks after and mitral valve replacement( MVR) using a bioprosthesis was performed. Oral antibiotic therapy was continued for six months after MVR to avoid infection recurrence. One year after MVR, the size of multiple liver metastases increased despite oral anticancer drugs administration. A totally implantable central venous access port( CV port) was placed and intravenous chemotherapy was started for progressive metastatic colorectal cancer. But the CV port was removed due to device infection caused by multiple drug resistant Staphyrococcus lugdunensis one month later, but the patient developed prosthetic valve endocarditits( PVE) due to the same bacterium, that caused valve stenosis. Redo MVR was indicated because of progressive dyspnea and uncontrollable fever. The patient was discharged one month after redo MVR, but suffered carcinomatous peritonitis, and eventually died eight months post-discharge. Chemotherapy needs caution because of potential risk of PVE in patients with prosthetic valves, especially for those with a history of infectious endocarditis.

[Anomalous Origin of Right Coronary Artery with Intramural Course, Aortic Valve Stenosis and Coronary Artery Stenosis:Report of a Case].

Anomalous origin of the coronary artery is a rare congenital malformation that can cause myocardial ischemia and arrhythmia in patients with or without atherosclerotic lesions. We present a case of aortic stenosis (AS) and coronary artery stenosis complicated by anomalous origin of the right coronary artery (RCA) from the aortic valve sinus and its intramural course. The patient was a 66-year-old woman who was diagnosed with AS 4 years prior, and scheduled for surgery owing to gradual progression of stenosis. Preoperative coronary angiography revealed an abnormal origin of the RCA, and during the surgery, the RCA was found located within the aortic wall close to the aortotomy. Thus, bypass surgery was performed using a great saphenous vein, to prevent ischemia of the RCA territory. The patient had good intraoperative and postoperative course, and a coronary computed tomography scan clearly showed the reconstructed RCA.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair.

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

[Effectiveness of tolvaptan for postoperative heart failure in a patient with combined valvular disease and pulmonary hypertension].

We report a case of a 60-year-old man with postoperative congestive heart failure( CHF) successfully treated with tolvaptan. The patient was diagnosed with pulmonary hypertension due to mitral stenosis and regurgitation combined with tricuspid regurgitation. He underwent mitral and tricuspid valvuloplasty. His postoperative course was uneventful until CHF symptoms secondary to volume overload appeared on the 4th day. Congestion with pulmonary hypertension was treated with 0.042 µg/kg/min of intravenous human atrial natriuretic peptide (hANP). His condition improved, and on the 11th postoperative day, he was weaned off hANP;oral administration of 40 mg per day of furosemide was initiated. However, 2 days after discontinuation of intravenous hANP, CHF recurred and serum sodium decreased to 128 mEq/l. Oral tolvaptan 7.5 mg per day was added to the furosemide, and CHF and hyponatremia subsequently improved. In this case, oral tolvaptan was effective for the treatment of refractory CHF with pulmonary hypertension after cardiac surgery.

[Redo coronary artery bypass grafting after pneumonectomy].

A 77-year-old man who had undergone left pneumonectomy 16 years and quadruple coronary artery bypass grafting (CABG) 4 years previously presented with unstable angina pectoris. Coronary angiography revealed severe stenosis of the left main trunk and the proximal left anterior descending artery(LAD), and the severely narrowed left internal thoracic artery (LITA)-LAD graft. Computed tomography(CT) presented a marked shift of the heart and great vessels into the left hemithorax with a hyperinflated right lung crossing the midline. The LAD would not seem to be accessible by median sternotomy. Off-pump coronary artery bypass grafting (OPCAB) with a saphenous vein graft to LAD was performed through a rib-cross left thoracotomy. The patient's postoperative course was uneventful, and postoperative CT revealed a patent graft. OPCAB through rib-cross thoracotomy is safe and useful and can be an option for redo CABG, particularly in instances of previous pneumonectomy.

[Management of cardiopulmonary bypass during cardiac surgery for patients with heparin-induced thrombocytopenia].

We experienced 4 cases of open heart surgeries under preoperative diagnosis of heparin-induced thrombocytopenia(HIT). We performed operation with argatroban instead of heparin. The argatroban was administered intravenously with a bolus of 100 µg/kg. After activated clotting time(ACT)reached over 200 seconds, continuous infusion of argatroban was started, 1~2 µg/kg/min until the level of ACT over 250 in the case of off-pump coronary artery bypass grafting(OPCAB), with 6~10 µg/kg/min, or the level of ACT over 400 with the use of cardiopulmonary bypass (CPB). All cases required more than 60 minutes to achieve the target ACT level after starting the argatroban. In 1 case it was impossible to achieve target level of ACT by argatroban alone, and heparin was used concomitantly. In 1 case there was a complication of membrane occlusion of CPB. Open cardiac surgery with the use of argatroban required specific care for coagulation to complete operation.

[Succesful case of open heart surgery in a dialysis patient with infectious endocarditis and severe bone marrow suppression: report of a case].

We report a case of infectious endocarditis due to Corynebacterium species. The patient was 71-yearold man, who was on dialysis and had tracheostomy preoperatively. He went to the hospital complaining of dyspnea. He was diagnosed with congestive heart failure and treated after admission. His respiratory condition was exacerbated and he was intubated. Respiratory management prolonged over 2 weeks. Tracheostomy was performed. One month after admission, cardiac echo showed massive aortic valve regurgitation and vegetation of aortic valve. The patient was transferred to our hospital to undergo operation for aortic valve regurgitation and infectious endocarditis. In our hospital, labo data showed severe bone marrow suppresssion with white blood cell(WBC)1,700/µl, red blood cell(RBC)259×104/µl, platelet(PLT) 5.0×104/µl. Aortic valve replacement was performed. Because the patient had tracheostomy, we incised sternal bone in a T shape to avoid mediastinitis. After operation, patient recovered well and left hospital 48th day after the operation.

[Preserving autologous heart operation for dilated cardiomyopathy].

OBJECTIVE: We report non transplant surgical procedure (preserving autologous heart operation) for the patients with dilated cardiomyopathy( DCM), clinical outcomes, and the factor of predict prognosis. PATIENT AND METHOD: Since May 2000, 258 patients received surgical procedure for 11 years. SURGICAL PROCEDURES: We performed mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation (MR). We performed papirally muscule plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with MR due to mitral tethering. The surgical left ventricular reconstruction( SVR) was performed for the patients with dilated left ventricular. We use spackle tracking echocardiography to decide the type of SVR since 2008. RESULT: Hospital death was 18.2%, and late cardiac death was 27.5%.Almost the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 58%, 10 years survival was 39%. Preoperative condition, emergent operation, inotropic support, intra aortic balloon pumping(IABP),affect the prognosis. But left ventricular size did not affect it. CONCLUSION: Surgical treatment for the patient with DCM should be performed with stable preoperative condition.

[Acute Type A aortic dissection with superior mesenteric arterial dissection; report of a case].

We report a case of acute type A dissection with acute abdomen due to blood flow insufficiency in the superior mesenteric artery. A 73-year-old man was presented to hospital complaining sudden onset of chest pain. Contrast-enhanced computed tomography revealed a type A aortic dissection, that extended from the ascending aorta to the left common iliac atery. Superior mesenteric artery was compressed by the thrombosed false lumen. Epigastric pain was exacerbated acutely, we decided to treat the bowel ischemia 1st, and after that, if bowel ischemia was reversible, central repair operation performed. Emergent saphenous vein bypass was performed from the right external iliac artery to the superior mesenteric artery. Then total arch replacement was performed using cardiopulmonary bypass. The patient complicated with postoperative paralytic ileus, he completely recovered without bowel resection.

[Prevention of cerebral infarction in thoracic endovascular aneurysm repair(TEVAR) of distal aortic arch aneurysms; left subclavian artery balloon technique].

Thoracic endovascular aneurysm repair(TEVAR) has been applied more and more frequently to an atherosclerotic distal aortic arch aneurysm. Even if the procedure is successful, extensive cerebral infarction might occur, especially in the left vertebral artery area. We therefore devised a new method to prevent embolic events using a thrombectomy catheter with an end hole, which was placed at the origin of the letf subclavian artery via the radial artery. This simple left subclavian artery balloon technique not only prevents cerebral embolism in the left vertebral artery system, but also provides a position marker under X-ray, and enables tight compaction of the embolization coils.

[Repented Bentall operation for the case of aortitis with totally calcified ascending aortic allograft].

A 49-year-old male underwent re-do root Bentall operation with aortic allograft for the prosthetic valve detouchment due to aortitis syndrome 15 years ago (reported in 1998). He was presented with the hemolytic anemia due to severe aortic stenosis. The totally calcified aortic allograft was found by the computed tomography and chest X-ray. The allograft severely migrated to the sternum was approached by re-sternotomy under the circulatory arrest following the establishment of cardiopulmonary circulation and the 2nd-re-operation of root replacement was performed with composite graft with mechanical heart valve. He was discharged on foot on the 46th postoperative day. A tight follow-up is necessary for such a case of aortitis syndrome.

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report.

BACKGROUND: Failed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage. CASE PRESENTATION: A 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography. CONCLUSIONS: Improvement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

[Saphenous vein graft aneurysm after coronary artery bypass grafting surgery presenting with chronic heart failure].

An 82-year-old woman with a history of a coronary artery bypass grafting (CABG) 10 years prior was admitted because of general fatigue, appetite loss and systemic edema. She presented with a right pericardial mass on chest radiography. Echocardiogram and computed tomography (CT) revealed a 6.0 x 7.0 cm saphenous vein graft aneurysm (SVGA) compressing both right atrium and the right ventricle. She was successfully treated with the aneurysmal resection and postoperative course was uneventful. Although SVGA is an unusual complication after CABG, we recommend that any patient with a history of previous CABG who presents with a mediastinal mass should be evaluated for possibility of SVGA.

Prognosis of patients with gastric carcinoma treated in remote island hospitals in Japan: a multivariable analysis.

BACKGROUND: Treating gastric cancer in remote island hospitals remains a major clinical challenge. Factors affecting prognosis of patients treated in general hospitals are still at large. We sought to determine the characteristics of gastric cancer in the Amamiooshima (Amami) archipelago of Japan and also evaluated the independent prognostic factors by the Cox regression analysis. MATERIALS AND METHODS: A total of 125 patients treated in four sister hospitals in the Amami were analyzed. RESULTS: The median age of patients with resection was 74 years and almost 85% patients had diffuse type of cancer. The 5-year overall survival was 34% for all patients and 58% for those who had a resection. Among the several clinicopathological factors, operation method (distal vs. total gastrectomy), splenectomy, lymphatic and venous invasion, T-stage, metastatic lymph node (MLN) size n-stage and UICC N-stage had significant impact on survival. Only MLN size and intraoperative blood loss had independent effect on survival by multivariable analysis. CONCLUSION: Improved perioperative care may yield a reasonable patient survival in elderly patients with gastric carcinoma treated in remote hospitals. Restricting amount of intraoperative blood loss may further improve the patient prognosis and MLN size may serve as a new metric to stage gastric cancers.

Pre-Operative Left Ventricular Torsion, QRS Width/CRT, and Post-Mitral Surgery Outcomes in Patients With Nonischemic, Chronic, Severe Secondary Mitral Regurgitation.

The selection of appropriate candidates for mitral surgery among symptomatic patients with nonischemic, chronic, secondary severe mitral regurgitation (NICSMR) remains a clinical challenge. We studied 50 consecutive symptomatic NICSMR patients for a median follow-up of 2.5 years after mitral surgery and concluded that the pre-operative 2-dimensional speckle tracking echocardiography-derived left ventricular torsional profile and QRS width/cardiac resynchronization therapy are potentially important prognostic indicators for post-surgery survival and reverse remodeling.

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis.

PURPOSE: Ischemic heart disease (IHD) may result in lethal conditions such as ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). METHODS: We hypothesized preoperative LV volume would be highly associated with long-term survival in such patients. We retrospectively evaluated effects of LV end-systolic volume index (LVESVI) on survival. RESULTS: Patients were divided into two groups according to LVESVI; Group S (n = 19, <100 ml/m(2)), and L (n = 55, >100 ml/m(2)). There were 74 patients (male 61, female 13; 61 ± 10 y.o.). There was no statistical significance in preoperative parameters, including ejection fraction (EF), severity of MR, severity of tricuspid regurgitation (TR), and right ventricular systolic pressure (RVSP). After operation, LVESVI and severity of MR were statistically reduced in both groups. However, EF, severity of TR and RVSP were not statistically alleviated in both groups. In Group S, 5- and 10-year survival rates were 93% and 48%. In Group L, 5- and 10-year survival rates were 50% and 29%. There was a statistical difference in long-term survival between two groups. CONCLUSIONS: Preoperative LV volume would be one of the risk factors for long-term survival in patients with congestive heart failure secondary to IHD. Careful follow-up and optimal treatment should be recommended before LV dimension becomes too large.

Sublocalization of Cardiac Involvement in Sarcoidosis and Surgical Exclusion in Patients With Congestive Heart Failure.

BACKGROUND: In sarcoidosis, cardiac involvement can cause fatal conditions such as left ventricular (LV) dysfunction and rhythm disturbance. We surgically treated critical patients with congestive heart failure due to cardiac sarcoidosis. METHODS: During 14 years, 384 patients with nonischemic dilated cardiomyopathy were operated. Among them, 14 patients (3.6%) with New York Heart Association (NYHA) class IV (male/female, 3/11; 57 ± 11 years) caused by sarcoidosis underwent surgery (elective/emergent, 12/2). The akinetic lesion, as identified by speckle-tracking echocardiography, was excluded. RESULTS: Localization of akinetic lesions was achieved in 13 patients (93%). In the short axis, lesional distribution was higher in the anterior (62%) and septal segments (54%) when compared with the posterior (31%) and lateral segments (23%). Along the long axis, regional distribution was higher in the mid (85%) and apical segments (69%) when compared with the basal segment (31%). The main lesions were excluded by septal anterior ventricular exclusion (n = 5), posterior restoration procedure (n = 3), endoventricular circular patch plasty (n = 3), and linear resection (n = 2). Mitral valve surgery included mitral valve plasty (n = 7) and replacement (n = 7). In patients undergoing elective surgery, early results showed that 10 patients survived (83%) and NYHA class improved (6 patients in class II and 4 in class III). Patients who underwent emergent surgery did not survive. The observation period was 55 ± 59 months in survivors. During follow-up, 4 patients died after 42 ± 48 months. The other 5 patients have survived for 71 ± 61 months. The 3- and 5-year survival rates were 65% and 52%, respectively. CONCLUSIONS: Sarcoidosis can result in sublocalized LV involvement, which can be surgically excluded.

Preoperative transaortic forward flow: Prediction of surgical outcomes in patients with DCM and mitral regurgitation.

BACKGROUND: In patients with dilated cardiomyopathy and mitral regurgitation, preoperative prognostic factors are very important. METHODS: We hypothesized that preoperative transaortic forward flow might be related to postoperative survival, despite mitral regurgitant volume. We retrospectively evaluated surgical outcomes and echocardiographic parameters, including forward flow through the aortic valve. RESULTS: Seventy-nine patients (54 males, 25 females; mean age 59 ± 12 years) with dilated cardiomyopathy and mitral regurgitation were divided into two groups according to postoperative outcome: 19 patients in group A suffered cardiac death, 60 in group B survived or died of another cause. In group A, death occurred after 227 ± 116 days, group B patients survived (except one who died of infection) for 505 ± 446 days; p < 0.01. Preoperatively, there was no significant difference in ejection fraction, end-diastolic and end-systolic volume index, mitral regurgitant volume, effective regurgitant orifice area, or right ventricular systolic pressure. Preoperative transaortic forward flow was significantly lower in group A vs. group B (1.57 ± 0.33 vs. 1.81 ± 0.46 L m(-2); p 0.04). In group B, transaortic forward flow was increased significantly before discharge (1.81 ± 0.51 vs. 2.43 ± 0.62 L m(-2); p < 0.01). Ejection fraction was significantly alleviated before discharge (28% ± 9% vs. 23% ± 8%; p < 0.01) and recovered to the preoperative value without repeat dilation of the left ventricle in late follow-up. CONCLUSIONS: Preoperative transaortic forward flow may be a predictor of survival in patients with dilated cardiomyopathy and mitral regurgitation, irrespective of mitral regurgitant volume.

Posterior restoration procedures and the long-term results in indicated patients with dilated cardiomyopathy †.

OBJECTIVES: Non-transplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. We performed posterior restoration for dilated akinetic or dyskinetic lesions in patients with DCM and obtained favourable outcomes. The early and long-term results of the procedures are discussed. METHODS: Between 2005 and 2013, posterior restoration procedures (PRPs) for DCM were electively performed in 58 patients (17 with ischaemic and 41 with non-ischaemic DCM). There were 45 men and 13 women with a mean age of 56 ± 12 years old. The mean preoperative ejection fraction was 24% and the preoperative New York Heart Association functional class was Class III in 24 and Class IV in 34 patients with intravenous inotrope support. Indications for PRPs were determined by using speckle-tracking echocardiography of the posterior region of the left ventricle before surgery (GE ultrasound machine, Vivid 7 or Vivid E9). After cardioplegic arrest, mitral surgery or coronary artery bypass grafting (CABG) was performed and the posterior left ventricular (LV) muscle between bilateral papillary muscles was incised or resected. The LV apex was preserved and cryoablation was applied between the cut edge and the posterior mitral annulus. All patients were followed up by transthoracic echocardiography. RESULTS: In addition to PRP, mitral surgery was performed in 56 (plasty 51, replacement 5), tricuspid annuloplasty in 21, CABG in 17, cardiac resynchronization therapy in 6 and LV lead implantation in 27 patients. Perioperative intra-aortic balloon pumping was used in 9 patients and there was no hospital mortality. After the operation, 35 patients (60%) improved their functional class to Class I or II. In the late follow-up, there were 14 cardiac deaths (congestive heart failure 10, ventricular arrhythmia 4). The 3- and 8-year survival rates were 77 or 66%, respectively. CONCLUSIONS: DCM with posterior akinesis or dyskinesis indicated by speckle-tracking echocardiography can be surgically treated with PRP. Our results demonstrated that 60% of the selected patients could avoid heart transplantation with relief of their symptoms.