[Mitral valve plasty for acute infective endocarditis; report of a case].

A 68-year-old woman was admitted with congestive heart failure and septic shock associated with suspected mitral valve acute infective endocarditis. Echocardiography revealed vegetations attached to both mitral leaflets, prolapse of the posterior mitral leaflet and severe mitral regurgitation. Emergent surgery was performed. The anterior mitral leaflet displayed multiple vegetations. The entire anterior leaflet of mitral valve was replaced with pericardium. The posterior mitral leaflet of the middle scallop was prolapsed with an attached vegetation. Quadrangular resection was performed. A commissural reconstruction by sliding commissuroplasty for a prolapse of both anterior and posterior leaflets in the paracommissural area and autologous pericardial mitral annuloplasty was performed. Mitral regurgitation disappeared postoperatively, and the patient is now doing well as of 5 years postoperatively.

[Therapeutic strategies for postinfarction left ventricular free wall rupture].

We treated 93 patients who developed left ventricular free wall rupture after acute myocardial infarction. Medical management including pericardial drainage was performed in 78 patients (84%), but 67 of them died. All 11 surviving patients showed an oozing type rupture. Surgical repair was performed in 15 patients (16%). As a result, 9 patients died and 6 survived. All but 1 of the patients who died presented with a blow-out rupture. Blow-out type rupture occurred in 3 and oozing type rupture in 3 of the surviving patients. One patient with blow-out type rupture underwent implantation of a left ventricular assist device following percutaneous cardiopulmonary support (PCPS), because of low output syndrome after the operation. The device was successfully removed 7 days after implantation. In all of the 3 patients with oozing type rupture, sutureless technique was successfully performed using fibrin-glue or fibrin-glue sheet fixation. After a mean follow-up period of 7 years after operation, 5 of 6 are still alive. To improve the clinical outcome of left ventricular free wall rupture, it is important for surgeons to closely liaise with physicians, to perform surgical repair as soon as possible, and to utilize a circulatory support system after operation. Therefore, we developed a new PCPS system compatible with emergency cardiac surgery and a new left ventricular assist system draining via the left ventricle.

[Recurrent right atrial myxoma five years after removal of left atrial myxoma; report of a case].

A 41-year-old man had undergone resection of a left atrial myxoma 5 years previously. Echocardiography revealed a new mass in the right atrium. Because of had increased in size gradually, removal of the right atrial mass involving full-thickness resection of the fossa ovalis was performed. Cardiac myxoma has the potential for heterotopic recurrence.

Reoperative minimally invasive axillocoronary artery bypass to the obtuse marginal branch.

A 73-year-old man was admitted with unstable angina, having severe coronary artery disease involving 3 vessels. He had undergone coronary artery bypass grafting to the left anterior descending artery and the obtuse marginal branch using saphenous vein grafts in 1979. Computed tomography showed severe calcium deposition and atherosclerosis in the ascending and descending aorta. We conducted axillocoronary artery bypass to the obtuse marginal branch and left internal thoracic artery as an in situ graft to the left anterior descending artery without cardiopulmonary bypass. Grafts were satisfactory and clinical results good.

[Surgical strategy for tricuspid valve disease].

The most common cause of tricuspid valve dysfunction is functional tricuspid regurgitation (TR) secondary to mitral valve disease. Annuloplasty is feasible in most patients with functional TR, and valve repair can also be performed in most patients with tricuspid valve dysfunction of other etiologies. Valve replacement is considered to be indicated only for those patients whose tricuspid valves have severe organic change or have been damaged by infective endocarditis. Although good long-term results of tricuspid valve replacement using bioprostheses have been reported, a bileaflet mechanical prosthesis may be an acceptable alternative in those patients who undergo concomitant valve replacement with a mechanical prosthesis in the mitral or aortic position or who may have persisting pulmonary hypertension after surgery.

Saccular aneurysm of pulmonary autograft after the Ross procedure.

The Ross procedure, which includes removal of the malformed aortic valve and replacement of a pulmonary autograft in the aortic position, has increased the number of available treatment options. Recently, dilatation of the autograft pulmonary root after the Ross procedure has been reported as a complication. We report a patient with bicuspid aortic valve malformations and aortic annulus dilatation, who had a saccular-form, true-type, aneurysm in the pulmonary autograft seven months after the Ross procedure. These changes have not been described so far as complication. Pathologically, marked mucoid degeneration was noted in the tunica media of the aneurysm, as well as in the original aortic root. These findings may suggest similar pathological characteristics between the aorta and pulmonary arteries. Hence, the surgical risks accompanying vascular characteristics in patients with congenital aortic valve malformations should be considered.

[Surgical treatment for mitral regurgitation: mid-term outcome following mitral valve repair].

Mid-term results of mitral valve repair for mitral regurgitation were evaluated in 173 consecutive patients (mean age 53 years, 107 males, 66 females) treated from July 1991 to March 1998. Pathological causes of the mitral valve disease were degenerative in 118 patients, infective endocarditis in 25, rheumatic in 13, and ischemic in 8 (ischemic cardiomyopathy in 7). The principal technique was chordal replacement with expanded polytetrafluoroethylene sutures for prolapse of the anterior leaflet, and Carpentier's sliding leaflet technique for prolapse of the posterior leaflet. Most patients received ring annuloplasty with a rigid ring and flexible band (physiological remodeling annuloplasty). Intraoperative transesophageal echocardiography was used after 1993. There were 7 operative deaths (4%) and 7 mitral valve replacements (4%) during the same operation. Successful repair was achieved in 96% of patients with mitral regurgitation. Mean follow-up was 35 months (range 2 to 78 months). Survival at 6 years was 85 +/- 10% of all patients, 98 +/- 2% in degenerative cases. Six patients required reoperation (1.2%/patient-year) and mean time interval between initial operation and reoperation was 33.1 months. Four patients with atrial fibrillation had thromboembolic events (0.8%/patient-year). There were no anticoagulant-related complications. Freedom from reoperation and all valve-related event at 6 years was 88 +/- 6% and 84 +/- 6%. Late postoperative Doppler echocardiography revealed satisfactory results in 93% of the patients. Mitral valve repair using chordal replacement, sliding plasty and ring annuloplasty provides excellent mid-term results.

Mitral valve repair by Carpentier-Edwards physio annuloplasty ring.

A semi-flexible annuloplasty ring (Physio-ring) was clinically used in 30 cases of mitral valve insufficiency. The Physio-ring has the characteristics in which the anterior section is rigid and has a saddle-shaped curve, while the posterior section is flexible to allow for changes in size and shape of the anulus during ventricular contraction. The patients were aged from 23 to 73 years (mean 53.8 +/- 12.5). The cause of mitral valve insufficiency was degenerative (in 24 patients), rheumatic (2), ischemic (1), endocarditis (1), congenital + degenerative (1), and traumatic (1). On the 6-month post-implant echocardiogram, 96.6% had grade 0 or +1 regurgitation. The effective valve orifice area was 2.61 +/- 0.82 cm2 (n = 19). There was no late death. However, there was 1 (3.3%) hospital death after the patient had received a simultaneous coronary artery bypass grafting, and then developed low output syndrome after surgery. Although there was no device-related complication, hemolysis of undetermined cause was observed in 1 (3.3%) patient. The findings from this study indicated a low incidence of device-related complication, while excellent valvular function was maintained.

Postoperative toxic shock syndrome caused by a highly virulent methicillin-resistant Staphylococcus aureus strain.

We report on a rare fatal case of postoperative toxic shock syndrome caused by infection with a highly virulent methicillin-resistant Staphylococcus aureus strain, designated Sak-1, which was found to be characteristic in its increased production of toxic shock syndrome toxin 1 in human whole blood (about 30-fold more than produced in Tod Hewitt broth). The strain also produced a high level of toxic shock syndrome toxin 1 in the circulating blood of mice experimentally infected with the strain.

Intraoperative TEE during mitral valve repair: does it predict early and late postoperative mitral valve dysfunction?

BACKGROUND: Intraoperative transesophageal echocardiography (TEE) using color Doppler flow mapping can accurately measure residual mitral regurgitation (MR), but it is unknown to what extent such measurements correlate with those obtained with postoperative transthoracic echocardiography (TTE). METHODS: We used intraoperative TEE (based on direct planimetry of the maximal regurgitant jet area) to measure residual MR in 42 patients who underwent mitral valve reconstruction for MR and compared these measurements with those obtained with early and late postoperative TTE. RESULTS: Residual MR as measured by intraoperative TEE correlated significantly with values obtained with both early (r = 0.66; p < 0.0001) and late (r = 0.71; p < 0.0001) postoperative TTE. Forty patients with no or trivial MR (< or =2 cm2) as measured by intraoperative TEE also had no or trivial MR as measured by early (probability of 87.5%) and late (probability of 80.0%) postoperative TEE. Of the 40 patients, 6 had clinically insignificant mild MR (< or =4 cm2) when measured by late postoperative TTE. Two other patients in whom intraoperative TEE showed mild MR developed moderate regurgitation about 3 months later. CONCLUSIONS: Intraoperative TEE correlates with early and late postoperative TTE in measurement of residual MR, suggesting it can reliably predict early and late postoperative mitral valve dysfunction.

[Pitfalls in echocardiographic diagnosis of mitral bileaflet prolapse].

Preoperative echocardiography provides good planning information for successful repair of mitral valve regurgitation, but identifying the prolapse of both the anterior and posterior leaflets is sometimes difficult. To clarify the cause of this problem, preoperative echocardiographic findings and intraoperative observations of the prolapse were analyzed in 124 patients with non-rheumatic pure mitral regurgitation. In 48 patients with final diagnoses of bileaflet prolapse, 16 (33%) were considered to have only single leaflet prolapse before the operation. Anterior leaflet prolapse was overlooked in 14, and prolapse of either of its commissural segments was the least detectable by echocardiography. Chordal rupture was seen more in the posterior leaflet than in the anterior leaflet. Movement of the anterior leaflet may be influenced by a prolapsed and hypermobile posterior leaflet and/or regurgitant jet flow caused by the posterior leaflet prolapse.

[A study of minimally invasive direct coronary artery bypass (MIDCAB): comparison of low risk group and high risk group].

We started to perform MIDCAB for the cases of markedly low cardiac function from June, 1996 and obtained satisfactory results. So we expanded the indications to include only left anterior descending artery (LAD) lesion from June, 1997 and have since performed this operation on 14 cases. The 14 cases of MIDCAB were divided into two groups, Group L consisting of 6 low risk cases: 1 lesion alone without any complications involving other organ before operation and Group H made up of 8 high risk cases: multi branch lesion but rated as high risk because of the extracorporeal circulation being used. Both Group L and Group H were free of operation death and hospital death. In Group L, all the cases underwent operation without blood transfusion, the period of postoperative stay in ICU was not longer than 1 day, on catecholamine was required after operation and complications were not found either. The patency of the graft was 100 percent. The patients were discharged 13.7 days after operation. In Group H, 2 cases required blood transfusion and 3 cases required catecholamine after operation. Complication arising from operative wound were noted in 3 cases. One GEA graft to the right coronary artery and one LITA to the LAD buried in the muscle were occluded. After operation, hospital stay for 23.9 days was required. In Group L, the postoperative course was excellent, so MIDCAB was considered indicated well for this group. In Group H too, the selection of MIDCAB was considered adequate that the risk of conventional CABG is considered much higher.

[Coronary artery bypass grafting with arterial graft alone: radial artery and inferior epigastric artery used in combination].

UNLABELLED: We experienced 8 cases in which Coronary Artery Bypass Grafting (CABG) was performed by the arterial graft alone with radial artery (RA) and inferior epigastric artery (IEA) used in addition to internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). All the patients were male ranging in age from 50 to 66 years (mean 57.5 year). The number of anastomosis was 3 to 5 branches (mean 3.6 branches). IEA was anastomosed with LITA and used as a composite graft in all cases. As for the proximal anastomosis of RA it was anastomosesd with ascending aorta. On postoperative radiography of graft, LITA, RITA, IEA and RA were all patent and RGEA was occluded only in one anastomosis where it was sequentially used (96.6%). All the patients followed a satisfactory postoperative course, and no case developed any major complications. CONCLUSION: The use of IEA and RA made it possible to perform CABG using only the artery with excellent postoperative results and early patency rate of the graft.

Right-sided partial sternotomy for minimally invasive valve operation: "open door method".

A simple technique for minimally invasive valve operations is described. With a 10-cm midline skin incision, excellent exposure of both the mitral and aortic valves is achieved through a right-sided partial sternotomy, which enables us to perform easy repair or replacement of these valves.

[Minimally invasive mitral surgery: mitral valve repair with a right-sided partial sternotomy].

We describe our concept and the results of mitral valve repair using a right-sided partial sternotomy. We performed mitral valve repair using this method in 50 patients with severe MR between April 1997 and October 1998. In 10 patients in whom good exposure was not attained, we changed to the ordinary full-sternotomy or T-shaped partial sternotomyprocedure. Forty patients with good exposure underwent successful mitral valve repair. The sites of repair were anterior in 15 cases, posterior in 16, and both in 9. There was no mortality, and intraoperative TEE performed in all 40 patients revealed that all had trivial or no regurgitation. The right-sided partial sternotomy (open door method) is a safe and useful method for minimally invasive valve Surgery. A better quality of life compared with traditional median sternotomy can be ensured for patients undergoing minimally invasive cardiac surgery only when receive the best-quality Surgery is performed.

[Radial artery for coronary artery bypass graft].

Early postoperative results were studied in 50 cases of coronary artery bypass graft (CABG) using a radial artery (RA). The patients ranged in age from 37 to 81 years, with the mean age of 61 years. Of them, 49 were male. An average of RA was 17.6 cm at completion of detachment and 15.6 cm when the graft was cut for use. The internal diameter before anastomosis an average of 3.7 mm on the proximal side and an average of 2.8 mm on the distal side. RA was anastomosed with ascending aorta in 47 cases, with the left internal thoracic artery in 2 cases and with the right internal thoracic artery in one case on the proximal side. RA was anastomosed with the left anterior descending branch area in 6 cases, with the left circumflex branch area in 40 cases and with the right coronary artery area in 4 cases on the distal side. There was no case of operative death, but one patient died while in hospital. The cumulative patency rate of the RA grafts was 95% (n = 40). Early postoperative results of the RA graft were satisfactory, therefore the RA graft were satisfactory, therefore the RA graft was an excellent alternative conduit for myocardial revascularization.

Severe hemolysis due to artificial chordae displacement.

Hemolytic anemia is a well-recognized complication of mechanical heart valve prosthesis but, as yet, has not been reported after mitral valve repair with chordal replacement. We report a case of severe hemolytic anemia after mitral valve repair with chordal replacement and Carpentier-Edwards annuloplasty ring insertion. Progressive prolapse of the anterior leaflet due to the artificial chordae being too long caused recurrent regurgitation which was responsible for the hemolysis. The patient also had idiopathic thrombocytopenic purpura, but successful second mitral valve repair was performed after high-dose gamma-globulin therapy.

Physiologic remodeling annuloplasty to retain the shape of the anterior leaflet: a new concept in mitral valve repair.

BACKGROUND AND AIMS OF THE STUDY: The Carpentier-Edwards (CE) ring was developed to restore the normal 3:4 ratio between the anteroposterior and transverse diameters of the mitral valve orifice during systole. It is difficult to use in patients in whom the ratio is more than 3:4. To overcome this problem, we developed an adjustable obturator, the ratio of which may be changed by sliding apart its two components. METHODS: Remodeling annuloplasty was performed using part of a flexible Duran ring or autologous pericardium and the adjustable obturator in 17 patients with severe MR, including two with high anterior leaflet. RESULTS: Physiologic remodeling annuloplasty was easily accomplished in all cases. Intraoperative echocardiography was performed in 14 patients, and it showed no regurgitant jet in 11 cases and only trivial jet in three. CONCLUSION: Physiologic remodeling annuloplasty to retain the natural shape of the anterior leaflet by using an adjustable obturator is a very useful technique that enables annuloplasty to be performed in all cases, irrespective of the shape of the anterior leaflet.