[Angina Pectoris due to Anomalous Aortic Origin of the Right Coronary Artery;Report of a Case].

A 45-year-old woman was admitted to our hospital because of chest pain on exertion. She was diagnosed to have an anomalous aortic origin of the right coronary artery(RCA) arising from the left sinus of Valsalva, passing between the aorta and the main pulmonary artery. Exercise treadmill test demonstrated significant depression of ST segments in leads II, III and aVF.Because medical treatment was ineffective, reimplantation of the RCA was performed. Dysfunction of the reimplanted RCA occurred, however 3 hours after surgery, and emergency coronary artery bypass grafting was performed using a saphenous vein graft to the RCA. After the 2nd operation, postoperative course was uneventful and multidetector row computed tomographic angiography revealed the patent vein graft and narrowing of the relocated site of RCA.

[Beating Mitral Valve Replacement for Functional Mitral Regurgitation after Cardiac Resynchronization Therapy;Report of a Case].

A 72-year-old man was admitted to our hospital because of dyspnea. He had a history of cardiac resynchronization therapy for congestive heart failure due to dilated cardiomyopathy 6 months previously. Echocardiography revealed severe functional mitral regurgitation which had been mild 6 months before. Because medical treatment was ineffective, on-pump beating mitral valve replacement using a bioprosthesis was performed to prevent reperfusion injury. The patient was easily weaned from cardiopulmonary bypass with low-dose inotropic support and scheduled intra-aortic balloon pump. Then, he was discharged in a good condition on the 37th postoperative day. Beating mitral valve replacement seems to be a good surgical option for patients with poor left ventricular function.

[Double Valve Replacement and Tricuspid Annuloplasty in a Patient with Situs Inversus Totalis and Mirror-image Dextrocardia;Report of a Case].

Situs inversus totalis and mirror-image dextrocardia is a rare congenital anomaly. A 79-year-old man with a history of atrial fibrillation presented to our hospital with chest oppression. Chest X-ray and computed tomography showed mirror-image dextrocardia and situs inversus totalis. Echocardiography revealed severe mitral and aortic regurgitation and mild tricuspid regurgitation. Mitral and aortic valve replacement using bioprosthesises, tricuspid annuloplasty and closure of the left atrial appendage were successfully performed. Surgical procedures were mainly performed by the surgeon standing on the left side of the patient, and by the assistant standing on the right side when necessary. The patient was discharged in good condition on the 23th postoperative day.

[Early outcomes of isolated aortic valve replacement in octogenarians].

We retrospectively studied early outcomes of isolated aortic valve replacement (AVR)in octogenarians. From November 2006 to October 2012, 70 patients underwent AVR and we divided them into 2 groups:group O (24 patients aged 80 years or older, 80~91 years;mean age, 85.0 years);and group Y(46 patients aged younger than 80, 39~79 years;mean age, 69.0 years). There were no significant differences in preoperative comorbidities between the groups, but the logistic EuroSCORE( 13.5% in the group O, 5.3%in the group Y) and EuroSCORE II (4.5% in the group O, 1.7% in the group Y) were significantly higher in the group O. The amount of blood transfusion needed was greater in the group O, but there were no differences between the groups with regard to the operation time, cardiopulmonary bypass time or aortic cross-clamp time. Operative mortality (4.2% in the group O, 2.2%in the group Y)and postoperative complications were not significantly different between the groups. Early outcomes of AVR in octogenarians were good and the newly refined EuroSCORE II showed a good correlation within the studied population.

An expanded polytetrafluoroethylene-autologous aortic hybrid valve for right ventricular outflow tract reconstruction in the Ross procedure.

Although the Ross procedure is a well-established approach to aortic valve disease in pediatric patients and young adults, there still is no ideal method of right ventricular outflow tract (RVOT) reconstruction, especially in children. To achieve improved RVOT reconstruction with long-term valve function and growth potential, we have developed a hybrid valve which combines the autologous aortic valve and expanded polytetrafluoroethylene (ePTFE) valves. The posterior wall of RVOT was reconstructed using the autologous aortic wall with a noncoronary cusp, and the anterior wall was reconstructed using a patch made of bovine pericardium or ePTFE with bicuspid ePTFE valves. We implanted hybrid valves in 14 patients (age 5-18 years). During the follow-up period (2.4-8.8 years), there were no mortalities or morbidities, and no patients required reoperation. Echocardiography showed no significant stenosis and regurgitation, and preserved valve motion in all patients. The z-value of the diameters of the pulmonary annulus in early and late follow-up was -1.4 and -1.8, respectively, the difference not being significant. Creation of a hybrid valve was associated with excellent mid- to long-term results. Given its theoretical growth potential, we speculate that this valve could be a good choice for RVOT reconstruction in the Ross procedure, especially for young children.

One-stage unifocalization followed by staged Fontan operation.

We report a successful case of staged Fontan operation for single ventricle, pulmonary atresia, major aortopulmonary collaterals and absent central pulmonary artery. The one-stage unifocalization, concomitant with central pulmonary artery creation by autologous pericardium and modified Blalock-Taussig shunt at 1 month of age as the first palliation, and the Glenn operation and pulmonary arterial augmentation with superior vena caval patch at 9 months of age as the second palliation were performed. Extracardiac conduit Fontan operation was completed at 22 months of age. The pulmonary artery continued developing with increasing pulmonary arterial index and stable pulmonary arterial pressure throughout the clinical course. The one-stage unifocalization in early infancy and the repeated surgical intervention to the pulmonary artery without prosthetic material provided excellent pulmonary arterial growth and Fontan completion.

Pulmonary arterial reconstruction for pulmonary coarctation in early infancy.

BACKGROUND: Pulmonary atresia with pulmonary coarctation may complicate diminished and unbalanced pulmonary development. The aim of this study is to assess the outcome of pulmonary arterial reconstruction with cardiopulmonary bypass in early infancy for sufficient and balanced pulmonary development. METHODS: We performed a retrospective review of 15 patients with pulmonary coarctation younger than 4 months of age who underwent pulmonary arterial reconstruction between 2001 and 2005. The mean age and weight were 42.2 days and 3.62 kg, respectively. The patient population included 5 biventricular repair candidates and 10 Fontan candidates. To evaluate the pulmonary arterial development, the preoperative and postoperative pulmonary arterial index and minimum diameter of the pulmonary artery were compared. RESULTS: No early or in-hospital deaths occurred, and there was no nonconfluent pulmonary artery development or segmental mal-development after a mean follow-up period of 14.9 months. Immediate pulmonary flow regulation was required in 2 patients because of excessive pulmonary flow. The mean pulmonary arterial index increased significantly from 103 mm2/m2 to 343 mm2/m2, and the mean minimum diameter of the pulmonary artery increased significantly from 2.02 mm to 4.45 mm. Four biventricular repair candidates completed definitive repair, and 2 required surgical reintervention in the pulmonary artery. Six Fontan candidates completed the Glenn procedure, and 1 completed the Fontan procedure. Three required surgical reintervention in the pulmonary artery. Two late deaths occurred after the Glenn procedure because of ventricular dysfunction and respiratory infection. CONCLUSIONS: Pulmonary arterial reconstruction in early infancy provides sufficient and balanced pulmonary arterial development for pulmonary atresia with pulmonary coarctation.

Atrial septal defect repair through limited lateral thoracotomy in children.

OBJECTIVE: We have developed a surgical method for atrial septal defect repair through a limited right lateral thoracotomy in which the incision line begins 2 cm caudal from the lower angle of the scapula and ends at the midaxial line, thereby improving patient satisfaction with the cosmetic results of treatment. METHODS: We performed a retrospective review of 28 patients who underwent isolated atrial septal defect repair through a limited right lateral thoracotomy between January 2002 and August 2004. The mean age and mean body weight at the time of the operation were 85.8 months (range 9-236 months) and 23.0 kg (range 8.0-56.0 kg), respectively. All repaired defects were the ostium secundum type. RESULTS: There was no operative or late mortality and no late morbidity after a mean follow-up of 26 months (range 12-41 months). Echocardiography showed no residual shunt in any of the patients. The mean length of the skin incision was 7.8 cm (range 5.0-11.0 cm), and almost all the patients had satisfactory cosmetic results. CONCLUSION: The atrial septal defect repair through a limited right lateral thoracotomy in pediatric patients showed satisfactory surgical results and excellent cosmetic results.

Pulmonary artery augmentation using autologous vena cava in right heart bypass operations.

We obtained good results in the right heart bypass operation concomitant with the pulmonary arterial augmentation using the vena cava in 7 patients. We report the techniques used in 2 representative patients. The techniques used were a hemi-Fontan procedure with large superior vena caval patches and a bidirectional cavopulmonary shunt with superior vena caval interposition. These techniques have advantages in that the augmented pulmonary arteries have growth potential and low thrombogenicity because the procedures can be performed without the use of prosthetic materials or xenografts, especially in cases in which it is impossible to use the autologous pericardium.

Infectious ductal aneurysm after coil embolization in an infant.

We report a case of ductal aneurysm after transcatheter coil embolization in an infant. The aneurysm was asymptomatic and was not detected until it ruptured during surgical intervention. We suspect that the aneurysm was induced by methicillin-resistant Staphylococcus aureus infection, as the resected aneurysmal wall was severely infiltrated by inflammatory cells and the patient had recurrent methicillin-resistant Staphylococcus aureus infection. We recommend remaining on guard against formation of a ductal aneurysm after coil embolization, especially in patients with associated recurrent bacteremia.

One-stage unifocalization and palliative right ventricular outflow tract reconstruction.

We report a successful case of one-stage unifocalization concomitant with palliative right ventricular outflow tract reconstruction for pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries and central pulmonary arterial absence. Through a median sternotomy, one-stage unifocalization was accomplished using autologous pericardial conduit and no prosthetic material. To achieve an adequate pulmonary blood flow, the right ventricular outflow tract was reconstructed so that it would be 70% of the normal pulmonary annular diameter, while the ventricular septal defect was left open. One-stage unifocalization concomitant with palliative right ventricular outflow tract reconstruction is considered to be a good surgical option for selected patients with these diseases.

Coronary artery obstruction due to membranous ridge of the right sinus valsalva associated with Tetralogy of Fallot: syncope mimics anoxic spell.

We report an infant with Tetralogy of Fallot who had suffered from repetitive attacks of syncope without obvious cyanosis. Careful observation by means of echocardiography and angiography revealed that the attacks resulted from acute coronary artery obstruction due to membranous ridge covering the sinus Valsalva. Surgical resection of the abnormal ridge and repair of Tetralogy of Fallot successfully improved the patient's symptoms. Syncope in children should be extensively investigated to exclude obstruction of the coronary arteries.

New "right side median" approach for postoperative re-coarctation of the aorta.

Anatomic repair of postoperative recurrent coarctation of the aorta is surgically difficult using the conventional lateral approach. Therefore, we have developed a new approach to the stenotic aorta through a median sternotomy, involving division of the superior vena cava and left caudal displacement of the heart. This approach facilitates extensive dissection and mobilization of the descending aorta in the posterior mediastinum behind the heart and also facilitates direct anastomosis of the aortic arch and the descending aorta after resection of the stenosis. This approach is useful for anatomic repair of postoperative recurrent coarctation of the aorta and other posterior mediastinal procedures.

"Bay window" technique for the arterial switch operation of the transposition of the great arteries with complex coronary arteries.

BACKGROUND: The success of arterial switch operations for transposition of the great arteries largely depends on faultless coronary translocation and subsequent sufficient myocardial perfusion. However, in patients with complex coronary artery anatomy, coronary translocation is often difficult to perform by conventional surgical techniques alone. Therefore we developed the "bay window" technique as a useful adjunct in patients with complex coronary arteries undergoing concomitant coronary translocation and arterial switch operation. Early and midterm results of this technique are described. METHODS: Between September 2001 and February 2002, 4 patients with transposition of the great arteries with complex coronary arteries underwent arterial switch operation. The ages of the patients at the time of operation ranged from 8 to 52 days. Great arterial relationships were anteroposterior in 2 patients, right-oblique in 1, and side-by-side in 1. One patient also had ventricular septal defect. Coronary arterial patterns were as follows: absent left main trunk in 1 patient, short left main trunk in 1, and short right main trunk in 1. Both coronary arterial orifices were resected as a tall U-shaped cuff. The inferior half of the coronary cuff was sewn into a J-shaped incision on the pulmonary stump. The superior half of the coronary cuff was folded down inside to form a bay window channel. RESULTS: No coronary events occurred (ie, inclusive of coronary stenosis, myocardial infarction, and coronary death). Postoperative echocardiogram demonstrated normal ventricular wall motions in all 4 patients. CONCLUSIONS: The bay window technique is an innovative and simple surgical adjunct for translocating complex coronary arteries.