Aortic valve replacement in small patients.

OBJECTIVES: Asians are smaller than Europeans and North Americans, but aortic valve replacement (AVR) in small patients has not been examined. We aimed to compare short- and mid-term outcomes of AVR between small and non-small patients. METHODS: We retrospectively divided 173 patients who underwent AVR into small (S, n = 95) and non-small (NS, n = 78) groups according to body surface area (≤1.6 in men, ≤1.5 in women) and analyzed differences in baseline characteristics, procedural and post-procedural variables, and survival. RESULTS: Mean age differed significantly between the S and NS groups (71.9 ± 11.2 vs. 66.2 ± 9.8 years), as did the proportion of women (60.0% vs. 24.4%). Implanted valves (19.6 ± 1.6 mm vs. 20.7 ± 1.7 mm) were significantly smaller and more bioprosthetic valves (57.9% vs. 41.0%) were used in the S group. Effective orifice area index and the rate of moderate and severe patient-prosthesis mismatch were not significantly different. No significant intergroup differences were found in hospitalization duration, 30-day mortality, survival rates, or valve related complications. CONCLUSIONS: Small patients were older and the proportion of women was higher. The implanted aortic valves were smaller and more were biological prostheses. However, mortality rate did not differ and short- and mid-term outcomes were safe and favorable.

[Surgical intervention for active infective endocarditis; review].

In active infective endocarditis, the right time for surgical treatment must not be missed. Enlargement of the focus and cerebral embolism aggravate the condition, and markedly impair the patients' activities of daily living (ADL). Early diagnosis and prompt surgical intervention contribute to improvement in the therapeutic outcome.

[Mitral valve disease in elderly patients].

It seems that mitral valve surgery in patients older than 80 years increase against the background of the aging society. Basically, there are not particular differences between elderly patients and younger patients in procedures for diagnosis and operative indication in mitral valve diseases. However, cardiac surgery for patients older than 80 years has been reported to have high mortality rate. Therefore, it is necessary that we should evaluate and treat complications of important organs such as brain/coronary artery/lungs/liver/kidney, adequately. Our mortality rate of the whole mitral valve operations was 2.4% and that of patients older than 75 years was 7.9%. This result compares favorably with those reported from other institutions. However, when we perform mitral valve operations for patients older than 80 years, it is necessary to investigate activities of daily living and quality of life before and after the operation.

[Right ventricular myxoma with syncopal attach; report of a case].

Cardiac myxoma of right ventricle is rare. We report a 16-year-old girl who underwent an emergent surgical resection of right ventricular myxoma. She had syncopal attach in going to school and was referred to our hospital in emergency. There were no abnormal findings in brain computed tomography (CT) and electroencephalogram, but Levine IV/VI systolic ejection murmur was heard. Echocardiography and magnetic resonance imaging (MRI) revealed the presence of large mass in the right ventricle which was floating into the pulmonary artery. The tumor was removed completely through the both of main pulmonary artery and right atrium using cardiopulmonary bypass. The tumor was attached to the right ventricle free wall by a pedicle, which was 5 x 3 cm in size and was diagnosed as myxoma by histopathological examination.

Surgical treatment of abdominal aortic aneurysm associated with horseshoe kidney and coagulopathy case report.

The coexistence of horseshoe kidney and aortic aneurysm poses a technical challenge to the vascular surgeon during aneurysm repair. Whether to divide the renal isthmus and how to approach the aneurysm are still matters of controversy, and coagulopathy sometimes occurs in patients with nontreated abdominal aortic aneurysm (AAA). We describe the successful surgical repair of an AAA with horseshoe kidney via the transperitoneal approach and division of the renal isthmus by harmonic scalpel. Exclusion of a thrombosed aneurysm can ameliorate coagulopathy due to AAA.

Silicone gel sheets relieve pain and pruritus with clinical improvement of keloid: possible target of mast cells.

Silicone gel sheet treatment is widely used to treat hypertrophic scars and keloids since it is easily applied and prevents scar pain and itching. We used Cica-Care silicone gel sheets in the conservative treatment of six patients for 24 weeks and recorded pain, itching, redness, and scar elevation every 4 weeks. We also investigated the number of mast cells and Fas antigen expression in the lesional skin (one patient) before and after treatment. The pain and itching clearly decreased after 4 weeks of the silicone gel sheeting and disappeared after 12 weeks. Twelve weeks were required for a reduction in scar redness and elevation. After 24 weeks, a decrease in the number of mast cells and the enhanced expression of Fas antigen by lesional fibroblasts were observed. Thus, silicone gel sheeting is effective and safe, especially with more severe symptoms of pain and itching possibly induced by mediators derived from increased mast cells.

Impaired sweating function in adult atopic dermatitis: results of the quantitative sudomotor axon reflex test.

BACKGROUND: Impaired sweating is thought to be a cause of barrier dysfunction in atopic dermatitis (AD). OBJECTIVES: To examine the sweating function in AD in a quantitative manner. METHODS: We investigated the sweating response of lesional and non-lesional skin of adult patients with AD by a quantitative sudomotor axon reflex test in which the axon reflex is stimulated by acetylcholine iontophoresis. Sweat volume on the volar aspect of the forearm was measured in 18 adult patients with AD and in 40 non-atopic controls; five patients with Sjögren's syndrome were also studied as disease comparators. We also evaluated the sweating function in four AD patients after topical corticosteroid therapy. Latency time, direct (DIR) sweat volume and axon reflex-mediated indirect (AXR) sweat volume were the variables studied. RESULTS: The latency time in AD patients was significantly prolonged and AXR sweat volume significantly reduced compared with those in non-atopic control subjects. The latency time and AXR sweat volume of lesional AD skin were significantly more prolonged and reduced, respectively, than those of non-lesional skin. In contrast, the DIR sweat volume of lesional or non-lesional AD skin induced by direct stimulation with acetylcholine was only slightly reduced when compared with that in non-atopic controls. Latency time and sweat volumes of lesional and non-lesional AD skin improved after topical corticosteroid therapy. CONCLUSIONS: These results suggest that the impaired sweat response in AD is attributable to an abnormal sudomotor axon reflex, which is reversed by topical corticosteroid administration.

[Long-term results of aortic valve replacement].

In order to improve the quality of life after cardiac valvular surgery, new procedures and new prostheses have been developed in the past decade. Surgeons have many alternatives for the individual patient. However, some may only represent a trend without any clinical advantage, some may increase the surgical risk, and some may have limited indications for specific types of heart disease. Therefore the selection of the procedure and prosthesis is very important. The new mechanical valves have a thinner ring and cuff, providing a larger orifice for patients with a small aortic annulus, and enlargement procedures are now rarely required. Second-generation biological valves have been used for more than 15 years. In the aortic position in elderly patients, the rate of freedom from structural deterioration is over 90% at 15 years. The stentless valve is the most notable newer prosthesis and has significant hemodynamic advantages, associated with good myocardial remodeling.

Notes to avoid failure in mitral valvuloplasty.

Mitral valvuloplasty can be applied in many situations and is quite effective in many cases. However, since it requires surgical skill based on knowledge and experience, there is a risk for recurrent surgery and reoperation was necessary in 5-8% of all cases in the first three years. 80-95% required no reoperation in ten years. Reoperation was performed mostly in cases of active endocarditis and extensive anterior leaflet prolapse. Reasons for reoperation were incomplete repair, tissue injury on sutured portion, recurrent annulus dilatation, reprolongation of chordae and hemolysis. To attain better surgical results in of mitral valvuloplasty the basic technique should consist of the resection and suture method and the fragile portion should be sutured with a patch. Careful attention should be paid to attaining a good coaptation of leaflet at the end of repair, sufficient remodeling of dilated annulus and to careful suturing of the prosthetic ring. It is also important to have an experienced operator perform transesophageal echocardiogram, and if more than 2 cm2 residual regurgitation is observed, immediate examination and treatment should be performed. In case of mitral regurgitation after surgery, careful assessment for reoperation can contribute to good late surgical results.

Survival and sinus rhythm maintenance after modified Cox/maze procedure and mitral valve operation in patients with chronic atrial fibrillation.

OBJECTIVE: Sinus rhythm gained after the Cox/maze procedure concomitant with mitral valve operation has demonstrated long-term attrition during the follow-up, no information exists on whether the type of mitral valve operation--(repair vs. replacement)--affects this sinus rhythm maintenance rate. We retrospectively studied patients undergoing concomitant mitral valve operation and Cox/maze procedure to answer this question. METHODS: Between April 1993 and August 1995, 87 consecutive patients--35 men and 52 women (mean age: 59.3 years)--with chronic atrial fibrillation and mitral valve disease underwent the modified Cox/maze procedure and concomitant mitral valve operation, with 56 having mitral valve repair (repair group) and 31 mitral valve replacement (replacement group). Patients were followed up and changes in rhythm studied retrospectively. RESULTS: Follow-up for a mean 51.3 +/- 11.6 months was completed in 82 of 83 long-term survivors (99%). Repair group surgery survival was 98.1 +/- 1.9% at 1 year and 94.2 +/- 3.2% at 5 based on the Kaplan-Meier method. Replacement group surgery survival was 85.7 +/- 5.9% at 1 year and 82.9 +/- 6.4% at 5. Probability in sinus rhythm maintenance for the repair group at 1 year was 88.6 +/- 5.4% and at 5 years was 67.6 +/- 9.1%. Probability in sinus rhythm maintenance for the replacement group at 1 year was 95.7 +/- 4.3% and at 5 years was 65.0 +/- 11.1%. CONCLUSIONS: Medium-term results after the Cox/maze III procedure concomitant with mitral valve operation are good. The attrition of sinus rhythm maintenance appears similar by the completion of 5-year follow-up.

Annuloaortic repair in the treatment of aortic regurgitation and aortic root pathology.

We developed a new technique of aortic root repair which may be able to eliminate the potential problem of leaflet damage, resulting from the direct contact of the aortic leaflets with synthetic vascular grafts during systole. This report describes our technique of annuloaortic repair and the operative results. Between February 1995 and October 1998, 13 patients underwent annuloaortic repair. The patients included 8 males and 5 females (mean age 50 years). Four patients had grade IV/IV aortic regurgitation (AR), 5 had III/IV AR, 2 had II/IV AR, and 1 had no AR preoperatively. Regarding the preoperative functional status, 1 patient was classified as New York Heart Association class IV, 5 were class III, 6 class II, and 1 class I. Concomitant cardiovascular procedures were performed in 12 cases. Aortic valvuloplasty or annuloplasty was performed in 7 patients. Both operative and short-term postoperative results with pre- and postoperative echocardiographic findings were studied retrospectively. The mean total cardiopulmonary bypass time was 212 min. The mean aortic cross-clamp time was 130 min. Circulatory arrest was induced in 5 patients. Postoperatively, 7 patients had no AR. Three patients had grade I/IV AR and 3 had grade II/IV AR. Perioperative changes in aortic annulus, mid-sinus portion, and sinotubular junction diameters were determined echocardiographically in 5 patients. The preoperative diameters were 2.7 +/- 0.4, 5.4 +/- 0.5, and 4.7 +/- 1.0 cm, respectively. The postoperative diameters were 2.3 +/- 0.5, 4.2 +/- 0.5, and 3.5 +/- 0.5cm, respectively. Ten patients were class I and 2 were class II. This technique of annuloaortic repair with or without aortic valvuloplasty is applicable to a certain subset of patients with aortic root disease and AR. Both the indications for this procedure and the long-term results should be confirmed.

[A case of aconitine poisoning saved with cardiopulmonary bypass].

"Torikabuto" is a kind of plant which contains deadly poison. Its ingredient is aconitine alkaloids. We report a case of aconitine poisoning with fatal arrhythmia and acute pulmonary edema who was saved with cardio pulmonary bypass. A 41-year-old male ate to mistake "Torikabuto" for wild plant. He developed symptoms of dysarthria and admitted to our hospital. He developed ventricular tachycardia and fibrillation soon after his admission. Then he developed cardiogenic shock. He was resuscitated and supported with a percutaneous cardio pulmonary bypass. Ventricular tachycardia disappeared 24 hours after admittion. About 1 week later, cardio pulmonary bypass was terminated and about 3 months later, he discharged from our hospital.

Medium-term results after the modified Cox/Maze procedure combined with other cardiac surgery.

OBJECTIVE: Long-term results after the modified Cox/Maze III procedure combined with other cardiac procedure for the treatment of organic heart disease and chronic atrial fibrillation (AF) has not been clarified. This report describes our medium-term results after such operation. METHODS: Between March 1993 and August 1995, 104 consecutive patients with chronic AF underwent the modified Cox/Maze III procedure combined with other cardiac procedure. There were 100 long-term survivors. There were 45 men and 55 women, with ages ranging from 21 to 77 years (mean 59.7). Patients were followed up and changes in rhythm, need for pacemaker implantation, and the incidence of CNS (central nervous system) complications were retrospectively studied. RESULTS: The follow-up was complete in 103 patients and 99 long-term survivors (99%). The mean follow-up period was 44.6 +/- 1.1 months. In the immediate postoperative period, 73 patients regained sinus rhythm (SR group), 21 patients were in AF (AF group), and six patients underwent pacemaker implantation because of sick sinus syndrome (SSS). During the follow-up period, eight patients died. One- and 5-year survival rates (Kaplan-Meier) after surgery was 95.1 +/- 2.3 and 87.8 +/- 3.4% for the entire group. Preoperative NYHA class was 2.5 +/- 0.7 and medium-term NYHA class was 1.5 +/- 0.5. (P < 0.001) Changes in rhythm for the SR group were followed. Fifty-two patients of the SR group stayed in SR (72%), 16 patients converted back to AF (22%), and four patients had newly-developed SSS (6%) at follow-up period. Probability in SR maintenance for SR group at 1 year was 88.8 +/- 3.7% and at 5 years was 64.8 +/- 7.5%. Five patients experienced the CNS complication during the follow-up period. Two of the AF group and two of the SR group patients developed cerebral/cerebellar infarction. One of the SR group patients experienced small cerebral bleeding. CONCLUSIONS: The medium-term results after the modified Cox/Maze III procedure concomitant with other cardiac procedure are good with improved functional status and good survival rate. However, there seems to be gradual but constant attrition in the rate of SR maintenance in SR group.

[Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation].

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.

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.

Double valve repair and maze procedure for degenerative valvular disease and chronic atrial fibrillation.

A 61-year-old male with degenerative aortic valve regurgitation, mitral valve regurgitation and chronic atrial fibrillation underwent a combined reparative procedure consisting of aortic valve repair, mitral valve repair and maze procedure. Surgery was successful and postoperatively the patient is in NYHA class I, without anticoagulation. To the best of our knowledge, this is the first clinical report of this combined reparative surgery. As advances are made in valve repair surgery, it is expected that similar combined procedures will be performed more frequently in future. The benefits of avoiding valve replacement and anticoagulation after such combination treatment is discussed.

[Supervised cardiac rehabilitation for the patients with the disturbance of the motor function after cardiac surgery: the significance of physical therapists' participation].

There are sporadic instances of patients with the motor function disturbance of non-cardiac origin after cardiac surgery, and these patients may need prolonged post-operative cardiac rehabilitation. We established our cardiac rehabilitation program for post-operative patients and a total of 124 patients underwent the post-operative cardiac rehabilitation program (male 73, female 51, average age 60). Among them, 12 patients (9.7%) received the physical therapy for the disturbance of motor function post-operatively. These 12 patients were retrospectively studied. Physical therapies performed were the exercise therapy to improve the range of motion to prevent contracture in 3 patients with peroneal nerve palsy and drop foot, the exercise therapy for pre-operative or post-operative hemiplegia in 6 patients, the instruction of exercise for lumbago in 1 patient with spinal cord disease, respiratory physical therapy in 1 patient, and myotherapy for arthritis in 1 patient. Treatment with physical therapy was very useful in rehabilitating these patients. Active participation of physical therapists in cardiac rehabilitation for patients with the disturbance of motor function after cardiac surgery is possible. It is expected that their participation may improve the quality of life in this subset of patients.

[Early recovery after valvular heart surgery].

There have been published not a few reports concerning the early recovery from heart surgery. But most of them were restricted in CABG cases. We report our efforts and its results about the early recovery from valvular heart surgery. To make a contribution to the early recovery we have made some efforts since 1995, including normothermic perfusion, low-dose fentanyl and introduction of terminal warm blood cardioplegia. As the results, the tracheal intubation period was shortened from 12.6 +/- 5.3 (hour) to 6.7 +/- 4.1. The number of the cases who had tracheal extubation in the operative day increased from 27% to 84%. The postoperative cardiac function was satisfactory and there were no abdominal or neurologic disturbances among the patients those who were entered into the early recovery protocol. We obtained satisfied early recovery in safe after valvular heart surgery.

Serial Doppler echocardiographic evaluation of Carpentier-Edwards pericardial valve dysfunction: comparison with Ionescu-Shiley valve.

BACKGROUND: Doppler echocardiography is a valuable noninvasive method for evaluating of the occurrence and degree of either prosthetic valve stenosis or regurgitation. By using serial Doppler echocardiographic examination, we evaluated the incidence and the mode of the Carpentier-Edwards pericardial valve (CEPX) dysfunction compared with that of the Ionescu-Shiley valve (IS). METHODS AND RESULTS: After aortic and/or mitral valve replacement, 80 patients with CEPX and 111 with IS underwent Doppler echocardiography at intervals of at least 2 years after surgery. The average durations of follow-up were 6.1 +/- 2.9 years for patients with CEPX and 7.2 +/- 3.0 years for those with IS. Bioprosthetic valve stenosis was defined as reduced excursion of the bioprosthetic valve leaflets and peak gradient > or =60 mm Hg after aortic valve replacement and mean gradient > or =7 mm Hg after mitral valve replacement. Bioprosthetic valve regurgitation caused by bioprosthetic valve dysfunction was defined as grade > or =3 transvalvular regurgitation. In the aortic position, although there was no significant difference in the actuarial rate of freedom from bioprosthetic valve stenosis between patients with IS and those with CEPX (10 years after surgery, 88% +/- 7% vs 90%, NS), bioprosthetic regurgitation caused by bioprosthetic valve dysfunction occurred less frequently in patients with CEPX than in those with IS (10 years after surgery, 86% vs 54% +/- 9%, p < 0.05). In the mitral position, bioprosthetic valve stenosis occurred more frequently in patients with CEPX than in those with IS (10 years after surgery, 54% +/- 11% vs 72% +/- 8%, p < 0.01). Although grade > or =3 transvalvular bioprosthetic regurgitation occurred later in patients with CEPX than in those with IS, there was no significant difference in the actuarial rate of freedom from that regurgitation between patients with CEPX and those with IS (10 years after surgery, 63% +/- 10% vs 54% +/- 7%, NS). CONCLUSIONS: For aortic valve replacement, CEPX has good long-term durability because of the low incidence of bioprosthetic regurgitation. For mitral valve replacement, long-term durability of CEPX is poor, although medium-term durability is satisfactory.