The Impact of Aortic Valvular Calcium on Transcatheter Heart Valve Distortion.

OBJECTIVES: To investigate the relationship between the eccentric calcification of aortic valve and transcatheter heart valve (THV) distortion and the impact of THV distortion on echo parameters and clinical outcomes. BACKGROUND: The effects of eccentric calcification of the aortic valve on the THV distortion and the relationship between THV distortion and clinical impact were not fully understood. METHODS: Patients with symptomatic severe aortic stenosis who were undergoing THV implantation were enrolled. Patients underwent preprocedural, postprocedural multislice computed tomography (MSCT), and follow-up transthoracic echocardiogram (TTE). Delta calcium score (ΔCS) is defined as the difference between the maximum and minimal calcium scores of the three cusps, while valve distortion score (VDS) is defined as the difference between the longest and shortest stent frame, as obtained using MSCT. Patients were divided into two groups according to ΔCS: "noneccentric calcification group" and "eccentric calcification group." RESULTS: A total of 118 patients were enrolled (59 patients in noneccentric and 59 in eccentric calcification groups). VDS was significantly lower in the noneccentric calcification group than in the eccentric calcification group (1.31 ± 0.82 mm vs. 1.73 ± 0.76 mm, p=0.004). VDS was not associated with the degree of paravalvular leak (PVL) and aortic valvular mean pressure gradient (AVPG) at 30-day and 1-year follow-up TTE and the cumulative rates of all-cause death and rehospitalization at 2-year clinical follow-up. CONCLUSIONS: Eccentric valvular calcification was associated with longitudinal THV distortion. However, THV distortion was not associated with PVL, AVPG, and adverse clinical events during midterm follow-up.

Geometry of Tricuspid Valve Apparatus in Patients with Mitral Regurgitation due to Fibroelastic Deficiency versus Barlow Disease: A Real-Time Three-dimensional Transesophageal Echocardiography Study.

BACKGROUND: Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography. METHODS: Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n = 42) and FED (n = 64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1 month. RESULTS: TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8 ± 2.9 vs 9.2 ± 2.4 cm2, 4.6 ± 1.6 vs 2.3 ± 1.1 mm, and 1.3 ± 0.8 vs 0.3 ± 0.3 mL; all P < .01). In contrast, TV tenting height and tenting volume were smaller in BD than in FED (2.6 ± 1.5 vs 4.4 ± 2.4 mm and 0.3 ± 0.4 vs 0.9 ± 1.0 mL; both P < .01). These morphologic differences in TV were similar to those in MV. There was a strong correlation between MV billowing volume and TV billowing volumes (R = 0.83, P < .01). The prevalence of significant residual TR after TAP was greater in BD than in FED (35% vs 0%, P < .01). Moderate correlations between TV billowing height and volume and residual TR after TAP were observed (R = 0.47 and 0.49, respectively, both P < .01). CONCLUSIONS: Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

Thromboembolic acute myocardial infarction after aortic valve replacement using the Freestyle stentless aortic bioprosthesis with subcoronary valve replacement.

A 70-year-old woman with substernal chest pain lasting 2.5 h presented to the emergency department of our hospital. She had a history of aortic valve replacement with the Freestyle stentless aortic bioprosthesis for severe aortic regurgitation 7 years ago. The initial electrocardiogram showed sinus rhythm at a rate of 71 bpm with ST-segment slight elevation in leads II, III and aVF. She was diagnosed as having acute coronary syndrome and was referred for an urgent catheterization. Urgent coronary angiography revealed total occlusion in the distal segment of the right coronary artery. Furthermore, a cavity was revealed around the aortic annulus by the contrast leaked from the ostium of the right coronary artery during angiography. Contrast-enhanced computed tomography showed an enhanced cavity between the native aortic wall and the bioprosthesis and the defect in the cavity. We diagnosed the incompetence of the bioprosthesis and decided to perform repeat aortic valve replacement. During surgery, the presence of a thrombus was confirmed in the cavity. The finding indicated that this embolic event was due to the thrombus from the cavity.

[Right ventricular rupture due to blunt trauma diagnosed by MDCT; report of a case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

Conventional surgical repair of traumatic rupture of the thoracic aorta.

OBJECTIVE: Traumatic rupture of the thoracic aorta is a life-threatening injury requiring urgent surgical intervention. Despite recent improvements in resuscitation and emergency operative techniques, the outcomes of patients with multiple injuries are still associated with a high mortality rate. We retrospectively examined the preoperative demographic data, associated complications and mortality rate of these patients. MATERIALS AND METHODS: We analyzed the data (1991-2009) of 18 patients with acute traumatic rupture of the thoracic aorta. Most patients had rupture limited to the aortic isthmus and severe associated injuries in other organs. The aorta was repaired by direct suturing, patch plasty (n = 5; 27.7 %) or graft interposition (n = 9; 50 %). RESULTS: The overall mortality rate was 33.3 %. All six patients who underwent emergency surgery within 2 h died, four intra-operatively and two postoperatively. The causes of the intra-operative mortality were uncontrollable hemorrhage and irreversible cardiac arrest due to penetrating injury of the thoracic aorta and intercostal arteries in three patients, and uncontrollable hemorrhage due to severe liver laceration in one. The surgical complications (42.8 %) were acute lung injury (n = 2), liver insufficiency (n = 2), acute renal failure (n = 1) and cerebral infarction (n = 1). No patients had postsurgical paraplegia. The mean period between arrival and treatment and the mean Injury Severity Score were significantly higher in group D than in group A. CONCLUSION: To improve the outcome of traumatic thoracic aortic injury, the degree of multi-organ damage, the priority of treatment be evaluated accurately is important.

Left atrial myxoma complicated with an acute upper extremity embolism.

Atrial myxoma is the most common benign tumor of the heart. Patients who have atrial myxoma usually present with cardiac obstruction, arrhythmia, or peripheral embolization. We encountered an unusual case of acute upper extremity ischemia due to a massive atrial myxoma in a young man. A 38-year-old man was admitted to our hospital with an acute onset of severe, right upper extremity pain and paralysis while working. Neurologic examination yielded normal results, but the patient showed no palpable right radial or ulnar artery. Routine sonographic evaluation revealed acute aortic embolism in his right brachial artery. Because of his young age and otherwise healthy condition, we decided to perform transthoracic echocardiography, which showed a huge left atrial tumor, which we suspected to be myxoma. We then performed urgent concurrent open heart surgery and embolectomy to avoid further embolism. The microscopic findings of the resected tumor and embolism specimens were myxoma. He was discharged without complications.

Traumatic rupture of the false lumen in a patient with preexisting chronic dissection of the descending thoracic aorta.

A 63-year-old man was transported to the emergency medical center due to blunt chest trauma combined with a fractured left leg caused by a motorcycle accident. He complained of severe dyspnea. Contrast-enhanced computed tomography revealed chronic aortic dissection DeBakey III, mediastinal hematoma of high density just above the diaphragm around the aorta, and an intimal flap-like shadow in the false lumen. Traumatic aortic rupture (TAR) with chronic aortic dissection was suspected. Aortography showed no clear sign of leakage, but a double-contour density was found in the outer wall of the false lumen of the descending aorta just above the diaphragm. He was therefore diagnosed with TAR and underwent an emergency operation. At the operation, rupture in the outer wall of the preexisting false lumen was found and was directly sutured. Acute renal failure developed immediately after surgery, which improved after several hemodialyses. We consider our case rare because no report has been so far made on TAR with chronic dissection.

Rupture of a pseudo aneurysm of the abdominal aorta in a patient with human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection has an impact on all systems of the body, including the cardiovascular system. A 54-year-old man presented with abdominal pain. Enhanced computed tomography revealed rupture of a pseudoaneurysm of the abdominal aorta. After surgery, the patient tested positive for HIV. Histological examination of the resected aorta showed leukocytoclastic vasculitis, a characteristic feature of HIV-related vasculitis.

Congenital anomaly of the external iliac artery: a case report.

A 51-year-old man was admitted with acute ischemic pain in the left leg. An angiogram demonstrated a well-developed left internal iliac artery that appeared to be continuous with the left common femoral artery, but no left external iliac artery. The left superficial and proximal deep femoral arteries were obstructed with thrombi. At surgery it was revealed that the distal end of the left common iliac artery was continuous with the dilated left internal iliac artery, forming the continuation with the left common femoral artery in the pelvic cavity. The left external iliac artery was absent between the common iliac and femoral arteries.