Left ventricular outflow tract pseudoaneurysm after aortic valve replacement: case report.

A 68-year-old woman was admitted for angina pectoris and general fatigue without symptoms or signs of infective endocarditis. The patient had undergone re-replacement of an aortic prosthetic valve three months previously. Transesophageal echocardiography revealed an echo-free cavity in the mitral-aortic intervalvular fibrosa region just below the aortic annulus, communication of the echo-free cavity with the left ventricular outflow tract, and turbulent flow into the cavity. Left ventriculography revealed a cavity that arose just below the aortic prosthetic valve, and which expanded in systole and collapsed in diastole. Coronary angiography showed significant stenosis of the proximal right coronary artery, but neither stenoses nor compression were found in the left coronary artery. Patch closure of the pseudoaneurysm and aortic root replacement using a Freestyle valve with reconstruction of the coronary arteries were successfully performed. Surgical trauma to the intervalvular fibrosa during removal of the original prosthetic valve may have caused pseudoaneurysm formation in this patient.

Right atrial myxoma in a patient presenting with syncope.

We describe a case of right atrial myxoma in a 62-year-old woman presenting with syncope. The patient had a 4-month history of syncope and felt faint on lying flat in bed before the admission. Transthoracic and transesophageal echocardiography showed a large right atrial mass that was prolapsing through the tricuspid valve into the right ventricle during diastole. Coronary angiography revealed a tumor stain through the right coronary artery and no significant stenosis of the coronary arteries. During operation, cardiopulmonary bypass was initiated with cannulation into the aorta and retrograde femoral vein and superior vena caval cannulation. The large tumor was attached by a short stalk to the interatrial septum at the border of the fossa ovalis. The tumor and the interatrial septum including the stalk with a 1.5-2.0 cm cuff extending the full thickness of the septum were completely excised. A histologic examination of the tumor confirmed the diagnosis of cardiac myxoma. We emphasize a characteristic feature of syncopal attacks, and discuss the importance of prevention of intraoperative systemic and pulmonary tumor embolization resulting from venous cannulation for cardiopulmonary bypass in patients with right atrial myxomas.

Effects of calcium channel blocker azelnidipine on experimental abdominal aortic aneurysms.

PURPOSE: Azelnidipine has recently been recognized in vascular remodeling. However, the effects of azelnidipine on aneurysmal disease have not yet been studied. The aim of this study was to evaluate whether azelnidipine can inhibit a further expansion of aneurysmal disease. METHODS: Experimental abdominal aortic aneurysms (AAAs) were created in a rat model by perfusing elastase. The rats in the first group received no treatment (n=10). In the second group (n=10) azelnidipine (2 mg/kg) was administered to the animals from 3 days before perfusion. The aortic diameter (AD) was measured at the time of initial surgery and death on postoperative day 14. The production of matrix metalloproteinases (MMP)-2 and -9 was analyzed by gelatin zymography. RESULTS: The aortic diameter was smaller in the azelnidipine group than in the control (7.875+/-1.454 vs 10.745+/-0.551 mm, P<0.01). the active MMP-2 and MMP-9 levels decreased in the azelnidipine group. Hematoxylin-eosin and elastin staining revealed fewer changes in the inflammatory infiltrate and degradation of elastin in the azelnidipine group. CONCLUSION: Azelnidipine reduced the expansion of experimental AAAs. Azelnidipine therefore appears to influence the inflammatory oxidative response seen in AAAs while also decreasing the MMP-2 and MMP-9 levels. In addition, azelnidipine inhibited aortic dilatation.

Strategy for isolated iliac artery aneurysms.

We retrospectively reviewed 41 patients with isolated iliac artery aneurysms presenting over a 21-year period. The mean age was 72 years. Mean aneurysmal diameter was 6.0 cm (range, 3.2-13 cm). The aneurysms were located in the common iliac artery in 31 patients, internal iliac artery in 7, and both arteries in 3. Rupture occurred in 20 patients (49%). The frequency of rupture of isolated iliac artery aneurysms was significantly higher than that of abdominal aortic aneurysms (8%) during the same period. The 30-day mortality was 9.8%; death in all 4 patients was due to rupture of the aneurysm. The surgical procedure was aneurysmectomy and replacement with a bifurcated prosthetic graft in 24 patients (59%), closure of the common iliac artery with a femorofemoral crossover in 7, minilaparotomy in 3, thromboexclusion in 6, and endoluminal stent-graft repair in one. In contrast to abdominal aortic aneurysms, isolated iliac artery aneurysms can be treated by various methods other than replacement with a bifurcated prosthetic graft. When selecting a strategy for such aneurysms, it is important to choose an approach appropriate to the location and risk, because of the frequency of rupture.

A shorter skin incision technique for the repair of infrarenal abdominal aortic aneurysms.

PURPOSE: We evaluated the effectiveness of a shorter skin incision technique for the treatment of infrarenal abdominal aortic aneurysms (AAA). The aim of the present study was to evaluate whether or not the difference in the length of the skin incision contributed to an early recovery after the operation. METHODS: Between October 2001 and December 2004, we performed 105 elective repairs for AAA. The patients were divided into three groups according to the length of the skin incision as follows: group A, less than 15 cm, group B, from 15 cm to less than 20 cm, and group C, 20 cm or more. RESULTS: There was no significant difference in the intraoperative course among the three groups. The duration of paralytic ileus was shorter in group A than in group C (2.0 +/- 0.9 days versus 3.2 +/- 2.3 days; P = 0.0428). Although the periods before removal of nasogastric suction and before starting a solid diet were slightly shorter in group A than in groups B and C, there were no statistically significant differences. CONCLUSION: We define minimally invasive vascular surgery as surgery performed with a small abdominal skin incision that does not expose the intestine to air while providing a good operative field that does not place any undue stress on the surgeon.

Late re-operation for aortic and mitral Starr-Edwards ball valve prostheses.

Starr-Edwards ball valves removed more than 15 years after implantation were retrospectively investigated macroscopically. Eight patients required re-operation. Valve models used in the initial operations were a non-cloth-covered valve in 2 patients and a cloth-covered valve in 6. Two patients had replacement of an aortic ball valve (model 1260 and model 2320) and 6 underwent mitral valve replacement (model 6120 in one, model 6320 in 5). The mean time to re-operation was 23.0 +/- 4.8 years after implantation. Cloth wear causing significant hemolysis was observed in all cloth-covered valves, regardless of valve position. Autologous tissue growth was noted on the orifice ring and struts in both aortic and mitral prostheses. Thrombus formation was not found in any of the valves. Ball variance in silicone rubber balls was mild in the non-cloth-covered valves, even in the aortic position. The most significant problem with the cloth-covered ball valve was cloth wear. Cloth wear should always be considered when 15 years or more have passed since valve implantation. Significant hemolysis, elevation of lactate dehydrogenase values, and echocardiographic detection of transvalvular regurgitation are diagnostic of cloth wear, and are indications for replacement of a cloth-covered ball valve.

Initial and midterm results for repair of aortic diseases with handmade stent grafts.

BACKGROUND: The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs). METHODS AND RESULTS: Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41). CONCLUSION: The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.