[Debranching Endovascular Repair for Impending Rupture of Aortic Arch Aneurysm in an Eldery Patient;Report of a Case].

Recently, thoracic endovascular aortic repair( TEVAR) has emerged as an alternative to open repair. We reported a case of a 92-year-old woman who underwent successful TEVAR for impending rupture of aortic arch aneurysm. The patient presented with back pain. Computed tomography revealed an impending rupture site at the aortic arch and left hemothorax. First, an axilo-axilo-carotid artery bypass was performed, and then 2 thoracic stent grafts were deployed successfully. Her postoperative course was uneventful, and at day 20, she was discharged. Debranching TEVAR is an effective procedure for aortic arch aneurysms in elderly patients.

Surgical outcome of simultaneous carotid and cardiac surgery.

PURPOSE: The surgical outcome of a simultaneous carotid endarterectomy and cardiac surgery has not been clarified. This study retrospectively reviewed short- and mid-term outcomes after a carotid endarterectomy combined with valvular surgery or coronary artery bypass grafting (CABG). METHODS: Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range 59-86 years) underwent a carotid endarterectomy combined with cardiac surgery. The main indication for carotid endarterectomy was more than 75% carotid stenosis with or without cerebral ischemic symptom. Eight patients had a history of stroke or transient ischemic attack. Endarterectomy was performed under mild hypothermia and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass in all cases. Concomitant cardiac procedures were aortic valve replacement in 1 patient and CABG in 14 patients. RESULTS: There was no early death. Early neurological complications occurred in only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein increased significantly in those that suffered postoperative neurological complications. One patient died 6 months after the operation due to pneumonia. There was no myocardial infarction, and no events were observed in the late postoperative periods. CONCLUSIONS: Carotid endarterectomy can be safely performed in combination with cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels might be useful for predicting early neurological complications.

Multiple papillary fibroelastomas in rare locations of aortic valve and left ventricular outflow tract: a case report.

Papillary fibroelastoma (PFE) is the third most common primary neoplasm of the heart. The lesions generally appear singly, but multiple PFEs may rarely occur. The case is reported of multiple PFEs in a woman initially admitted for acute cerebral infarction. Echocardiography revealed four masses, one located on each cusp of the aortic valve and one on the left ventricular outflow tract. All four lesions were successfully removed surgically. An histopathologic examination revealed PFEs arising from the ventricular and valvular endocardium.

First clinical application of the DuraHeart centrifugal ventricular assist device for a Japanese patient.

The DuraHeart ventricular assist device (VAD) is a third-generation implantable centrifugal pump with a magnetically levitated impeller. Since February 2007, the device has been clinically applied with excellent results as a bridge to heart transplantation in Europe. As of this writing, however, the device has yet to be approved by the Ministry of Health, Labour and Welfare for clinical use in Japan. We herein report the first clinical application of this device for a Japanese patient. A 31-year-old man with dilated cardiomyopathy was transferred to the Heart and Diabetes Center NRW (HDZ-NRW) in Bad Oeynhausen, Germany, where he was to await heart transplantation. The transfer was safely completed under management with low-dose dopamine. His condition gradually deteriorated at HDZ-NRW, and the DuraHeart left ventricular assist device was implanted for the left ventricle at 7 weeks after admission. Shortly thereafter, however, on POD 7, a Thoratec VAD had to be inserted on the right side due to refractory right heart failure. The right ventricular assist device could be explanted after a 3-month assist, and the patient is now waiting for heart transplantation at home in Germany.

Successful treatment of fulminant myocarditis with mechanical circulatory support.

A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.

Vascular protecting effect of angiotensin receptor blocker (ARB) on the radial artery graft.

PURPOSE: We hypothesized that the vascular protecting effect of an angiotensin receptor blocker (ARB) reduced endothelial damage of the radial artery (RA) after coronary bypass and conducted a comparative study. PATIENTS AND METHODS: One hundred and sixty four patients were divided into the following two groups, Group C: 92 subjects who were orally administered Candesartan 8 mg/day, Group I: 72 subjects who were administered Imidapril at 5 mg/day. Graft angiography was performed one year after surgery and the RA intima was evaluated using an angioscope. RESULTS: Total cholesterol of Group C was 151.4+/-66.9 mg/dL, which was significantly lower than in Group I (182.2+/-27.8 mg/dL), and LDL cholesterol of the ARB-treated group, i.e., Group C was 96.1+/-32.5 mg/dL and significantly lower than in Group I (139.1+/-48.7 mg/dL). In angioscopy, yellow plaque was detected in the proximal RA in 7 (8.0%) and 8 (11.6%) patients of the Groups C and I, respectively, showing a lower tendency in the ARB-treated group. CONCLUSIONS: The results of evaluation one year after surgery revealed no significant difference in effects on the RA endothelium between ARB and ACE inhibitor. ARB reduced cholesterol and its effect was confirmed with blood examination data and endoscopic findings.

Coronary sinus dissection during left ventricular pacing electrode implantation.

Coronary sinus (CS) dissection during biventricular pacing electrode implantation is a complication that rarely develops. A 71-year-old female with recurrent ventricular tachycardia, heart decompensation, and poor left ventricular function because of dilated cardiomyopathy was admitted for the implantation of a cardioverter-defibrillator for biventricular pacing. During the operation, we experienced a CS dissection with hematoma in the left ventricle wall while introducing the guidance catheter into the CS. However, the pacing lead was successfully implanted into the posterolateral vein using the "over-the-wire" technique. The postoperative electrocardiogram showed a decreased QRS; meanwhile, the echocardiography revealed dimensional reduction and functional improvement of the left ventricle.

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.

A surgical case of left ventricular pseudoaneurysm complicating myocardial infarction in a diabetic patient on dialysis.

A 57-year-old man was hospitalized with dyspnea and heart failure. We performed an electrocardiogram, coronary angiogram, echocardiogram, and magnetic resonance imaging. He was diagnosed with a left ventricular pseudoaneurysm (i.e., heart tumor) at the posterolateral wall. Minimal contrast medium was utilized when making the diagnosis as the patient was on dialysis. We subsequently repaired the ventricular unruptured pseudoaneurysm and performed a coronary artery bypass grafting. This case presented difficulty in ascertaining the difference between a cardiac tumor and a ventricular pseudoaneurysm.

40 Years experience in mitral valve replacement using Starr-Edwards, St. Jude Medical and ATS valves.

BACKGROUND: We have used the Starr-Edwards ball (S-E) valve since 1963, the St. Jude Medical (SJM) valve since 1978, and the ATS valve, since 1993 as the first choice of mechanical valve. In this study, the results with each valve during the 40 years were investigated in single mitral valve replacement (MVR) cases. PATIENTS AND METHODS: The mean age for S-E valves was 32.8+/-11.1 years old (y.o.), for SJM it was 47.2+/-12.6 y.o. and for ATS it was 56.3+/-11.4 y.o., indicating the aging of patients over time. The operative mortality decreased over the same time from 10.3% to 5.2% then 1.4% respectively. A significant difference was observed among the 3 groups with regards to the valve-related complication-free rate and cardiac event-free rate. However, there was no significant difference among the 3 groups with the other complications. CONCLUSION: Although there are many cases of valve-related complications with S-E valves, they have a role as an initial stage mechanical valve. In view of the long-term results extending over 20 years, the SJM valves is considered as the most reliable valve. The ATS valve is expected to achieve favorable results in the future because it may improve the quality of life (QOL) of patients and produce fewer valve-related complications.

A non-operative survival case of an 84-year-old patient with type A acute aortic dissection complicated by pulseless tamponade.

An 84-year-old woman was hospitalized in hemodynamic shock due to type A acute aortic dissection (AAD) complicated by pulseless tamponade. She was treated conservatively as her family refused emergency surgery. In spite of warning her family that lack of intervention may possibly lead to an early death, she gradually improved and went home without any further problems. Emergency surgery for octogenarians remains controversial, however. We report the first surviving, non-operative case of an octogenarian with pulseless shock due to aortic dissection.

Surgical case of aortic root and thoracic aortic aneurysm after the Wheat procedure.

A 52 year-old man underwent aortic valve replacement and ascending aortic replacement (Wheat procedure) for acute dissection (Stanford type A) and aortic regurgitation (grade 3/4). At that time, the aortic root was slightly dilated at about 45 mm and the descending aorta was within a normal range at about 35 mm. Forty months after the initial operation, a follow-up chest enhanced computed tomography showed an aortic root aneurysm about 60 mm in diameter, a thoracic aortic aneurysm about 70 mm in diameter and chronic aortic dissection. First we performed the Bentall procedure, innominate artery and left common carotid artery replacement by 12 mm, and 10 mm Hemashield grafts during selective cerebral perfusion. After 10 weeks, we carried out aortic arch, descending aorta and left subclavian artery replacement. The postoperative course was uneventful and postoperative examination demonstrated a good surgical result. Histological findings of the aortic aneurysm wall showed cystic medial necrosis, but Marfan's syndrome was excluded clinically. We could diagnose aortic root aneurysm by regular follow-up chest enhanced computed tomography (CT) and echocardiography. Therefore, cases with slight dilation of the aortic root in the Wheat procedure should undergo regular follow-up evaluation by chest enhanced CT and echocardiography.

[Cerebral oxygen desaturation monitoring during off-pump coronary artery bypass grafting].

BACKGROUND: The evaluation of cerebral perfusion during off-pump coronary bypass grafting (OPCAB) has not been clarified. The aim of this study was to investigate the predictive value of neurobiochemical markers of brain damage and cerebral perfusion with respect to the neuropsychological outcomes after OPCAB. METHODS: Ten patients (4 males and 6 females) underwent OPCAB. All patients were performed brain CT preoperatively and 7 days postoperatively. We excluded the patients with cerebralvascular disease from this study. A 5.5 Fr oximetric catheter was placed in the jugular bulb, and we measured continuously SjO2 and mean arterial blood pressure during OPCAB. Venous serum level of neuron specific enolase (NSE) was measured preoperatively and 24 hours after skin closure. RESULTS: There was correlation between mean blood pressure and SjO2 during anastomoses. The mean blood pressure during anastomoses of left anterior descending coronary artery (LAD), circumflex coronary artery (Cx), right coronary artery (RCA) were 68.6 +/- 12.9 mmHg, 60.9 +/- 9.3 mmHg, 64.1 +/- 14.1 mmHg. The SjO2 during anastomoses of LAD, Cx, RCA were 57.3 +/- 10.9%, 48.6 +/- 9.8%, 57.7 +/- 18.2%. There is tendency that the SjO2 during anastomosis of Cx was lower than others. No patients died, and there was no permanent neurologic deficit. Postoperatively, 2 patients had abnormal high NSE level. CONCLUSION: Intraoperative continuous cerebral oxygen desaturation monitoring seems to be useful monitor for neuropsychological outcomes after OPCAB.

Successful bicuspid aortic valve repair using external aortic annuloplasty.

A 33-year-old man presented with severe aortic insufficiency due to a prolapsed bicuspid aortic valve. The ventriculoaortic junction was dilated to 29 mm without root dilatation, and external ring annuloplasty was performed using a Gelweave (Terumo, Tokyo, Japan) graft to reduce the size to 22 mm. The leaflets were repaired by dividing and suturing a raphe between the right and left cusps. This combination provided adequate coaptation depth (8 mm) and showed excellent results, with trivial aortic insufficiency. This approach is suitable for repair of a bicuspid aortic valve with a dilated ventriculoaortic junction without root dilatation.

Alternative technique for implanting an epicardial cardioverter defibrillation patch during a tricuspid valve replacement for arrhythmogenic right ventricular cardiomyopathy.

Transvenous endocardial cardioverter defibrillator lead implantation is contraindicated in patients with prosthetic tricuspid valves (TVs). A 61-year-old male was hospitalized due to right heart failure, severe TV regurgitation, and non-sustained ventricular tachycardia (VT), which required Sotalol. The patient received an implantable cardioverter defibrillator (ICD) using an epicardial cardioverter defibrillation patch during a TV replacement (TVR) for VT and severe TV regurgitation because of arrhythmogenic right ventricular cardiomyopathy. There were no complications and the stimulation thresholds were stable. ICD implantation with the use of an epicardial cardioverter defibrillation patch serves as a safe, easy and effective therapy for patients undergoing TVR complicated with ventricular arrhythmia.

Mid-term results of tricuspid annuloplasty using the MC3 ring for secondary tricuspid valve regurgitation.

We investigated mid-term outcomes after ring annuloplasty with the MC3 ring and aimed to identify factors associated with recurrent tricuspid regurgitation (TR). From October 2006 to October 2010, 136 patients (male:female 80:56, with a mean age 64.7±11.8 years) underwent tricuspid valve (TV) annuloplasty for functional TR. The indications for TV annuloplasty were (1) severe TR, or (2) mild or moderate TR with pulmonary hypertension (systolic pulmonary artery pressure >50 mmHg) or tricuspid annular (TA) dilatation, in patients undergoing mitral valve (MV) surgery. The average follow-up period was 1.5±0.8 years. The overall survival rates were 97.1±0.15%, 93.4 ± 0.02% and 90.7 ± 0.28% at three months, one year and four years, respectively. Freedom from recurrent moderate TR was 98.5±0.01, 95.6 ± 0.17% and 90.6 ± 0.03% at three months, one year and four years, respectively. Multivariate analysis revealed that residual TR was significantly associated with preoperative severe TR, left ventricular end-diastolic dimension >70 mm, right ventricular dimension >40 mm, dilated cardiomyopathy (DCM) and left ventriculoplasty. This MC3 ring corrects TR effectively, and provided good results. We must point out, however, that additional or alternative surgical options should still be considered for high-risk of repair failure, such as those with DCM or high pulmonary hypertension.

Left ventriculoplasty for dilated cardiomyopathy in Fukuyama-type muscular dystrophy.

A 29-year-old man was hospitalized because of heart failure causing dilated cardiomyopathy (DCM). On admission, he had elevated creatinine kinase levels (hyper CKemia) (4283IUl⁻) and false enlargement of bilateral calves. By a muscular biopsy, he was diagnosed as Fukuyama-type muscular dystrophy. Although neuromuscular diseases are often related to cardiomyopathy, reports showing a relation between cardiomyopathy and Fukuyama-type muscular dystrophy have been rare. Our group performed the partial left venticulectomy of the posterior wall and approximation of the papillary muscle, mitral valve annuloplasty, and tricuspid valve annuloplasty for DCM in the patient with Fukuyama-type muscular dystrophy, after obtaining informed consent from the patient and his family. At the 1-year follow-up examination, the neuromuscular symptoms had not progressed, and the left ventricular function was improved (left ventricular end-diastolic dimension (LVDd) 77-66 mm, left ventricular end-systolic dimension (LVDs) 73-59 mm, and ejection fraction (EF) 26-30%). This is the first case report of a left ventriculoplasty in a patient with Fukuyama-type muscular dystrophy.

A case report of central extracorporeal membrane oxygenation after implantation of a left ventricular assist system: femoral vein and left atrium cannulation for ECMO.

PURPOSE: The left ventricular assist system (LVAS) is often used for end-stage heart failure. However, in severe lung disorder, the patient needs extracorporeal membrane oxygenation (ECMO) because oxygenation using only a ventricular assist system (VAS) is insufficient. We report a successful case of combining the use of LVAS and right VAS (RVAS) with ECMO. METHOD: A 40-year-old female developed cardiogenic shock secondary to end-stage dilated cardiomyopathy, and percutaneous cardiopulmonary support (PCPS) was initiated. An echocardiogram showed a low ejection fraction (11%), and she underwent implantation of an LVAS (Toyobo Ventricular Assist System). She also required a RVAS with ECMO shunting between the right and left atrium because there was insufficient oxygenation resulting from pulmonary dysfunction followed by severe lung edema. RESULT: Pulmonary function recovered successfully, and the RVAS-ECMO was removed after 7 days of support. There were no complications after operation, such as infection, bleeding, or systemic embolization. CONCLUSION: LVAS combined with RVAS-ECMO in right and left atrial cannulation is a useful option for patients with severe pulmonary damage.

The CardioWest total artificial heart for chronic heart transplant rejection.

Mechanical circulatory support has been used to treat graft failure after heart transplantation, but in patients who needed mechanical circulatory support because of chronic rejection, we have suffered from the treatment because its outcome was catastrophic. Multiple organ failure was often caused by the addition of or increase in immunosuppressive medications, and it is known as a cause of the poor outcomes. The CardioWest total artificial heart was implanted for a case of chronic heart transplant rejection to enable complete withdrawal of immunosuppressive medication. The patient underwent re-heart transplantation, with a good result. This is a new therapeutic technique for chronic graft rejection.

Reconstructive surgery for an akinetic anterior ventricular wall in ischemic cardiomyopathy.

BACKGROUND: The purpose of this prospective study is to analyze the postoperative outcome after only left ventricular reconstruction (LVR) versus LVR combined with coronary artery bypass grafting (CABG) and/or mitral valve (MV) procedure in ischemic cardiomyopathy (ICM) as a result of an akinetic anterior ventricular wall. METHODS AND RESULTS: Nineteen patients underwent only LVR, and 37 underwent a concomitant LVR procedure. In both groups, New York Heart Association (NYHA) classification improved significantly from 3.5 +/- 0.6 to 2.2 +/- 0.5 (LVR group) and 3.4 +/- 0.7 to 2.5 +/- 0.5 (combined LVR group). Ejection fraction improved significantly from 25.1 +/- 3.2 to 35.3 +/- 4.5% in the LVR group and 28.1 +/- 2.2 to 37.6 +/- 5.5% in the combined LVR group. Cardiac index improved significantly from 1.8 +/- 0.6 to 2.3 +/- 0.5 l/min/m2 in the LVR group and 1.6 +/- 0.4 to 2.2 +/- 0.6 l/min/m2 in the combined LVR group. An additional concomitant procedure increased the mortality rate only slightly. The overall 1- and 5-year actuarial survival rates were 90% and 75% in the LVR group and 80% and 70% in the combined LVR group. CONCLUSIONS: The LVR for akinetic ventricular wall shows very satisfactory early and long-term results. The LVR, with or without concomitant procedures, has considerable benefits for operative therapy.