Successful application of the snare technique for the deployment of the proximal portion of a Zenith Alpha Thoracic Endovascular Graft: a case report.

BACKGROUND: Open surgery can be required or even fatal if incomplete deployment of stent graft (SG) occurs. We herein report the first case in which a snare was successfully used to perform endovascular therapeutic troubleshooting on the proximal portion of a Zenith Alpha thoracic endovascular graft proximal component that showed incomplete deployment. CASE PRESENTATION: The patient was an 80-year-old woman. She underwent thoracic endovascular aortic repair (TEVAR) for subacute phase Stanford type B ulcer-like projection aortic dissection. Although the ulcer-like projection disappeared, a follow-up computed tomography angiogram (CTA) obtained approximately 1 year postoperatively showed type Ia and Ib endoleaks. Since there is a high risk of rupture as the aneurysm diameter increases, we determined that an additional SG was indicated. An attempt was made to place the SG in Zone 3, but as the lesser curvature side of the proximal portion stopped in a position that was perpendicular to the vascular wall (downward facing), the SG proximal portion did not completely expand. A guiding sheath was inserted into the aortic arch via the left brachial artery, and, using a snare that we inserted via the femoral artery, we grasped the guiding sheath. A catheter and guidewire (GW) were inserted via the guiding sheath and then rotated under the lesser curvature of the SG proximal portion; the GW was then passed through the loop of the snare. This allowed us to insert the hard loop structure under the SG proximal portion, which in turn allowed successful repair of the incomplete deployment of the SG. Type Ia and Ib endoleaks remained but were less than those before additional TEVAR. One week later, she was discharged. One year later, CT showed no interval change in the size of aortic aneurysm with dissection, and she has been followed on an outpatient basis. CONCLUSIONS: When the endovascular diameter of the proximal aortic arch is large, incomplete deployment of the proximal portion of a Zenith Alpha thoracic endovascular graft can occur, but bailout is possible through the use of the snare technique as endovascular therapy.

A case of recurrent constrictive pericarditis induced by pericardial substitution with an expanded polytetrafluoroethylene membrane.

A 72-year-old man presented with recurrent constrictive pericarditis, which developed 6 months after pericardiectomy, and pericardial substitution with an expanded polytetrafluoroethylene membrane. Re-pericardiectomy was performed. A new thick membranous structure had grown under the expanded polytetrafluoroethylene membrane anterior to the right ventricle, and was firmly adhered to the epicardium. This new structure exhibited collagenous fiber-based fibrotic thickening, and resembled a foreign body reaction. It was surmised that recurrence of constrictive pericarditis may have been induced by the expanded polytetrafluoroethylene membrane. Heart failure resolved after the operation; however, the patient died of respiratory failure on postoperative day 6.

Impact of Lesion Localization on Durability of Mitral Valve Repair in Infective Endocarditis.

BACKGROUND: Mitral valve (MV) repair for infective endocarditis (IE) is sometimes challenging. We investigated the durability of repair associated with the location of the infected lesion. METHODS: The study comprised 83 patients (55 ± 18 years; active, 66; healed, 17) who underwent MV repair at our institution. Patients were categorized into 5 types based on the location of the main lesion: type I, posterior leaflet (n = 36); type IIC, clear zone of anterior leaflet (n = 12); type IIR, rough zone of anterior leaflet (n = 28); and type III, annulus (n = 7). Type IIR was divided into 2 subgroups: IIR-large (>1 segment involvement, n = 9) and IIR-small (1 segment, n = 19). RESULTS: Follow-up was 95.2% completed for 7.2 ± 5.2 years. The rate of recurrent moderate or severe mitral regurgitation (MR) was 2.8% in type I, 0% in type IIC, 28.6% in type IIR, and 14.3% in type III. The freedom from recurrent moderate or severe MR was significantly lower in type IIR compared with the other types (63.1% ± 10.6% vs 96.8 ± 3.2% at 5 years, P < .001). Moreover, the recurrence rate was higher in type IIR-large (55.6%) than in type IIR-small (15.8%, P = .068). Type IIR was an independent predictor of recurrent MR (hazard ratio, 11.1, 95% confidence interval, 2.52-78.2; P = .001). CONCLUSIONS: The durability of MV repair for IE was satisfactory in posterior leaflet infection without annulus invasion and in clear zone infection of the anterior leaflet. However, rough zone infection of the anterior leaflet, especially with more than 1 segment involvement, was associated with a high risk of recurrent MR.

Surgical technique of double valve replacement in a patient with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder. Left ventricle dilation and valve insufficiency are complications in patients with OI and such patients are at high risk of mortality and complications related to bleeding and tissue friability during cardiac surgery. Valve dehiscence due to extreme friability of the annulus is a major complication of cardiac valve replacement with OI. We describe OI in a male patient who underwent double valve replacement with mechanical valves using a tissue protective method to prevent valve dehiscence.

[Repair of Cardiac and Pulmonary Damage caused by Stabbing with a Kitchen Knife;Report of a Case].

A 51-year-old woman was stabbed in the chest with a kitchen knife. Twenty minutes after arrival at our hospital by ambulance, she was transferred to the operating room, and a cardiopulmonary bypass was established from the right femoral artery and vein, and a median sternotomy was performed. The knife had damaged the surface of the heart and penetrated the lingular segment of the left lung. Both wounds were directly sutured. Chest X-rays taken after closing the chest showed bleeding in the left lung probably because of the administration of heparin. Bleeding was controlled by lingulectomy. The postoperative course was uneventful.

Technical aspects of mitral valve repair in Barlow's valve with prolapse of both leaflets: triangular resection for excess tissue, sophisticated chordal replacement, and their combination (the restoration technique).

BACKGROUND: Histological degeneration in Barlow's valve mainly starts in the rough zone, frequently expands toward the chordae, and advances to the clear zone, resulting in a saccular aneurysm-like morphology in the prolapsed region. On this basis, we have repaired the prolapsed segment by triangular resection, chordal replacement and the combination (the restoration technique). The aim of this study was to report our initial findings and evaluate the efficacy of our technique. METHODS: Twelve patients diagnosed with Barlow's valve with prolapse of both leaflets (5 women; mean age, 49 years) underwent the restoration technique between January 2008 and March 2013. We retrospectively reviewed short-term clinical outcomes. The mean duration of the clinical follow-up was 2.5 ± 1.7 years. RESULTS: The restoration technique was successfully performed in all patients. Predominant repair techniques were isolated triangular resection (anterior 8, posterior 9), a combination of triangular resection with chordal replacement (anterior 1, posterior 1), and isolated chordal replacement (anterior 3, posterior 1). All patients underwent complete mitral annuloplasty, and the mean ring size was 31 ± 2 mm. In-hospital mortality was not noted. Late transthoracic echocardiography showed no or trace mitral regurgitation without significant systolic anterior motion in all patients. The New York Heart Association functional class was significantly improved from 1.3 ± 0.5 before surgery to 1.0 ± 0.0 after it (p < 0.01). There were no late thromboembolic or bleeding events. CONCLUSIONS: Initial experience with the restoration technique has provided excellent results without significant systolic anterior motion. Our technique may contribute to improve late results in Barlow's valve.

Outcome of surgical management for active mitral native valve infective endocarditis: a collective review of 57 patients.

OBJECTIVE: At our institutions, mitral valve vegetation with a high risk for embolism is surgically treated as soon as possible to maintain the quality of life of patients, and valve repair has been actively performed. We reviewed the surgical outcome for active mitral infective endocarditis (AMIE) following this treatment policy. METHODS: Fifty-seven patients underwent surgery for native AMIE between April 1999 and December 2012 (repair 36, replacement 21). We retrospectively investigated the risk factors for in-hospital death, the prognosis of patients with cerebral infarction, and the short- and long-term outcomes of valve repair and replacement. RESULTS: The preoperative conditions and the intraoperative findings in the replacement group were more complicated. But, no significant differences were observed in in-hospital mortality, 4-year survival, or 4-year reoperation-free rate between the groups (repair 8, 88.2, and 92.4%; replacement 9, 90.5, and 94.7%, respectively). The incidence of postoperative cardiac-related events including heart failure, thromboembolism, and major bleeding was higher in the replacement group. Although our study failed to identify predictors of in-hospital mortality, uncontrolled and nosocomial infections were responsible for high in-hospital mortality of 17 and 33%, respectively. Nine patients with symptomatic non-hemorrhagic cerebral infarction underwent early surgery within 2 weeks of the onset of stroke (median maximum infarct diameter and volume: 18.2 mm and 0.72 cm(3), respectively). No patients had severe hemorrhagic conversion. CONCLUSION: Mitral valve repair is appropriate to prevent postoperative cardiac-related events. Reducing in-hospital mortality due to uncontrolled infection remains challenging. Early surgery may be reasonable for patients with small non-hemorrhagic infarction.

Mitral leaflet restoration using a billowing leaflet in active infective endocarditis.

A key to the success of mitral valve repair in patients with infective endocarditis is the technique used for reconstruction of the missing leaflet. We report the case of a 47-year-old man with active mitral infective endocarditis. After dissection of the infected segments of P3 and the posteromedial commissure, the defect was reconstructed using tissue from a billowing A2 medial and A3 segment. Chordal transfer with an anterior chord was performed to correct the A3 mild prolapse. Follow-up echocardiography showed recovery of mitral valve morphology and function without regurgitation.

Are octogenarians in good condition after cardiac valvular surgery?

PURPOSE: With the aging of society in developed countries and advances in surgical technology in recent years, surgery is increasing in elderly patients. When performing surgery in older patients, both surgical outcomes and the maintenance of postoperative quality of life (QOL) are important issues. This study investigated surgical outcomes and postoperative QOL in octogenarians who underwent cardiac valvular surgery. METHODS AND RESULTS: Fifty-nine (16 males) octogenarians (80-89 years old, mean age, 82.4 ± 2.4 years) underwent cardiac valvular surgery between August 1999 and June 2011. A QOL questionnaire, which included the Barthel Index (BI), Fillenbaum Instrumental Activities of Daily Living (FIADL), and the Vitality Index (VI), was sent to all survivors. Kaplan-Meier analysis was used to assess survival. Hospital mortality was 1.6% (1 patient). The 3-, 5-, and 7-year survival rates were 81.2%, 75.4%, and 67.8%, respectively. The BI showed that 87.5% of patients did not require caregiving, the FIADL showed that 32.5% were highly independent, and the VI showed that 87.5% were motivated to live. CONCLUSIONS: Short-term outcomes were satisfactory, with low complication and mortality rates. Mid-term outcomes showed maintenance of the minimal required ADL and good motivation for living. However, independence in social activities was decreased, suggesting the need for comprehensive social support.

Video-assisted resection of papillary fibroelastoma arising from a miniature tendinous chord in the apex of the left ventricle.

We report a rare case of a papillary fibroelastoma (PFE) in the apex of the left ventricle.An 81-year-old woman with nonspecific symptoms was shown to have a mobile mass deep in the left ventricle. With videoscopic assistance, removal of the mass was accomplished through the mitral valve via a midline sternotomy under cardiopulmonary bypass. The tumor arose from a miniature tendinous chord in the apex, and histological examination revealed PFE. Videoscopy facilitated safe and effective removal of the lesion in this case.

Circumaortic left renal vein associated with juxtarenal abdominal aortic aneurysm.

The patient was an 82-year-old man who was found to have a juxtarenal abdominal aortic aneurysm accompanied by a circumaortic left renal vein (CLRV). During dissection of the proximal anastomosis site the CLRV was injured, but was successfully repaired. A graft implantation was performed below the renal arteries. The incidence of CLRV is thought to be rare, however it is found in 7% of cadavers donated for anatomy. CLRV may cause unexpected bleeding by inadvertent dissection of the abdominal aorta. To prevent unexpected bleeding, surgeons should always keep in mind this potential risk when performing surgery.

Which type of secondary tricuspid regurgitation accompanying mitral valve disease should be surgically treated?

PURPOSE: The purpose of this study was to examine changes in severity of secondary tricuspid regurgitation (TR) accompanying mitral valve disease, and to identify factors predicting failure of improvement in TR after mitral valve surgery. METHODS: We studied 99 patients who had TR of grade ≥2+ preoperatively, 47 with tricuspid annuloplasty (TAP Group) performed concurrently, and 52 with mitral surgery alone (nTAP Group). Predictors of failure of improvement in TR in the nTAP Group were analyzed. RESULTS: The mean follow-up period was 4.6 ± 2.7 years. There was a significant difference between the TAP and nTAP Groups in TR improvement (93.6% vs. 67.3% respectively, p <0.001) and in change of TR grade (-2.1 ± 1.0 vs. -0.9 ± 1.0 respectively, p <0.001). Univariate analysis in the nTAP Group identified rheumatic etiology, atrial fibrillation, mitral stenosis (MS), and large left atrium prior to surgery as risk factors for failure of improvement. In multivariate analysis atrial fibrillation was identified as a predictor of failure of improvement (p = 0.004). CONCLUSION: Our results suggest that TAP should be performed concurrently with mitral valve surgery in patients with secondary TR of grade ≥2+, especially those having atrial fibrillation, even if TR is not severe.

Active infective endocarditis due to Erysipelothrix rhusiopathiae: zoonosis caused by vancomycin-resistant gram-positive rod.

A 42-year-old female who was a voluntary worker in a school for handicapped children was referred to us for surgery for active infective endocarditis. Trans-esophageal echocardiography showed 2 large mobile vegetations on the aortic valve and severe aortic regurgitation. Aortic valve replacement was performed to prevent septic embolism and deterioration of congestive heart failure. The empiric therapy with vancomycin, ampicillin, and gentamycin was initiated because a pathogen was not identified. But Erysipelothrix rhusiopathiae (gram-positive rod) was isolated on the 4th day after surgery. The target therapy with penicillin G and clindamycin was started and continued for 4 weeks after surgery. The inflammatory parameters improved steadily and the patient was discharged on the 36th day after surgery. Infective endocarditis due to gram-positive rods can be easily mistaken for streptococci or dismissed as a skin contamination. But, E. rhusiopathiae endocarditis should be considered in the differential diagnosis.

Surgical experience with chronic constrictive pericarditis.

OBJECTIVE: Constrictive pericarditis is a disease characterized by marked thickening of the pericardium which causes restriction of diastolic cardiac function. The purpose of this report is to review the outcome of pericardiectomy for constrictive pericarditis and to discuss its problems. METHODS: Sixteen consecutive patients who underwent pericardiectomy for constrictive pericarditis in our institution between March 2000 and June 2011 were reviewed. All patients underwent decortication including at least the anterior surface from the right atrium to the left phrenic nerve and the diaphragmatic surface of the heart. The epicardium was concomitantly resectioned because it was usually sclerotic and constrictive. RESULTS: Postoperatively, mean central venous pressure decreased to 8.8 ± 3.1 mmHg and was significantly lower than the preoperative value 15.3 ± 3.7 mmHg (p < 0.001). The mean postoperative duration of hospitalization was 25.6 ± 13.5 days. There were 2 in-hospital deaths and early mortality rate was 12.5 %; however, excluding hospital deaths, there were no significant postoperative complications and all survivors recovered and maintained good cardiac function during the mean follow-up period of 3.7 ± 2.8 years. CONCLUSION: For an acceptable outcome, surgical intervention should be performed at an appropriate time and the pericardiectomy should have proper scope and depth to prevent irreversible changes in the heart, liver, and other organs.

Twelve years of experience with the ATS mechanical heart valve prostheses.

OBJECTIVE: The ATS Open Pivot mechanical heart valve has been implanted routinely at our institution since 1999. The objective of this study is to retrospectively analyze our 12-year clinical results with ATS prostheses. METHODS: ATS Open Pivot mechanical valves were implanted in 268 adult patients between May 1999 and August 2010. We selected 259 subjects who could be adequately followed (follow-up rate 96.6 %). Aortic valve replacement was performed in 157 patients, mitral valve replacement (MVR) in 71, and double (aortic and mitral) valve replacements (DVR) in 31. Mean age at the time of implant was 58.8 ± 10.6 years. The gender ratio was 128 males/131 females. Mean follow-up was 4.4 ± 7.8 years, and the cumulative follow-up was 1144 patient-years (pt-yr). RESULTS: Early death within 30 days after the operation occurred in 5 (2.5 %) patients. Late death occurred in 27 patients including valve-related deaths in 13. The 10-year survival rate after the operation was 82.7 ± 2.9 %. The rate of freedom from valve-related death was 92.2 ± 2.2 %. The incidence of valve-related complications was 2.19 %/pt-yr. Of these, the incidence of thromboembolic events and that of bleeding complications were 1.22 and that 0.87 %/pt-yr. The incidence of valve thrombosis was 0.09 %/pt-yr. No structural valve deterioration was observed in any of the three operative procedure groups. CONCLUSIONS: Our 12-year experience with aortic and MVR using the ATS mechanical heart valve demonstrated low incidences of thromboembolic events, bleeding complications, and valve thrombosis.

Characteristics and treatment strategies of mitral regurgitation associated with undifferentiated papillary muscle.

PURPOSE: In this report we review our experience of operations on mitral regurgitation associated with abnormal papillary muscles/chordae tendineae of the mitral valves and discussed the clinical characteristics, operative findings, and treatment strategies. METHODS: Undifferentiated papillary muscle was defined as a hypoplastic chordae tendineae with anomalous formation of papillary muscles attached to the mitral valves directly. Consecutive 87 patients undergoing surgery for mitral regurgitation at our institution were reviewed and 6 of them had undifferentiated papillary muscle. RESULTS: The underlying mechanism of regurgitation was prolapse at the center of the anterior leaflet in 3 cases and tethering, a wide area of myxomatous degeneration, and annular dilatation in one case, respectively. Five patients underwent mitral valve plasty and 1 patient received replacement. Anomalous formation of chordae tendineae was corrected by resection and suture with transplantation at the tip of the leaflet to which abnormal chordae were attached in 2 cases, while resection and suture with chordal shortening was performed in 1 case, and chordal reconstruction using artificial chordae was employed in 2 cases. There was no operative death, and postoperative echocardiography showed no residual regurgitation in any of the cases. CONCLUSIONS: Mitral regurgitation associated with undifferentiated papillary muscle resulted from prolapse or tethering and impaired flexibility of leaflets. It was possible to successfully treat the patients by mitral valve plasty unless complex congenital cardiac malformation coexisted. Detailed examinations of attached papillary muscle by echocardiography and intraoperative inspection are necessary and surgical techniques should be selected appropriately in each case.

Survival and quality of life of octogenarians who underwent mechanical valve replacement at a younger age.

PURPOSE: Mechanical valve replacement is associated with complications, however, there is little information on the quality of life (QOL) of octogenarians who had undergone mechanical valve replacement at a relatively younger age. We examined survival, valve-related events, and the QOL of octogenarians who had undergone mechanical valve replacement. METHODS: A total of 56 octogenarians who underwent mechanical valve replacement between 1969 and 1997 (age at the time of surgery, 65.6 ± 6.7 years), completed a questionnaire on survival, valve-related events, and QOL (basic activities of daily living, instrumental activities of daily living, mental health). RESULTS: The mean follow-up was 12.4 ± 6.6 years, and the cumulative follow-up period was 642.4 patient-years. Six valve-related deaths (0.9%/patient-year) were registered during the follow-up. Furthermore, 11 valve-related events (1.8%/patient-year) were recorded. The mean age of the 21 survivors was 82.9 ± 1.8 years, and 19 of the survivors lived at home. Their QOL was excellent. CONCLUSION: The valve-related deaths and events in octogenarians who had previously undergone mechanical valve replacement at a younger age were within acceptable limits. The QOL was similar to that of octogenarians described in previous studies.

Systolic anterior motion after mitral valve repair: predicting factors and management.

PURPOSE: The aim of this study was to determine the mechanism of systolic anterior motion (SAM) after mitral valve (MV) repair by analyzing the clinical data of patients with MV repair. METHODS: A total of 104 MV repairs were performed for patients with isolated degenerative posterior leaflet prolapse. Eight patients (7.7%) developed SAM with severe mitral regurgitation. We compared the preoperative and intraoperative findings of the two groups (8 patients in the SAM group, 96 in the non-SAM group) and reported the clinical courses of the SAM patients. RESULTS: Preoperative left ventricular end-diastolic and end-systolic diameters were significantly smaller and the preoperative left ventricular ejection fraction was significantly greater in the SAM group than in the non-SAM group. The number of patients with a sigmoid septum and the number with anterior leaflet-septal contact (LSC) during diastole were significantly larger in the SAM group. Incidence of billowing posterior leaflet, prolapsed segments, and operative techniques were comparable for the two groups. SAM improved with correction of hemodynamic status in four patients. In four other patients secondary cardiopulmonary bypass was required to resolve SAM. SAM resolved with additional repairs in two patients, whereas the other two required MV replacement. Of the six patients in whom conservative treatment or re-repair was successful, one had recurrent SAM 3 months after surgery. CONCLUSION: The sigmoid septum and LSC may predict SAM after MV repair. A strict follow-up is imperative for patients with persistent or recurrent SAM.

A case of pulmonary infective endarteritis associated with patent ductus arteriosus: surgical closure under circulatory arrest.

A 35-year-old man was admitted to the hospital with prolonged high-grade fever. Chest computed tomography revealed multiple pulmonary infiltrations in both lungs, suggesting septic emboli. Echocardiography revealed patent ductus arteriosus and mobile large vegetations in the pulmonary artery. Because of uncontrollable infection and the imminent possibility of massive pulmonary embolism, he underwent transpulmonary surgical closure of the ductus and resection of the vegetations under hypothermic circulatory arrest using cardiopulmonary bypass. We report a rare case of open heart surgery in a patient with pulmonary infective endarteritis associated with patent ductus arteriosus.