[Giant Right Coronary Artery Aneurysm Complicated by Acute Myocardial Infarction:Report of a Case].

The patient was a 45-year-old man who was transported by ambulance to a nearby clinic owing to sudden chest pain. He was diagnosed with myocardial infarction and giant coronary artery aneurysm by coronary arteriogram and underwent an emergency intervention for the myocardial infarction. The patient was referred to our hospital. Intraoperative findings showed the mass-like right coronary artery aneurysm at the anterior to the right atrium. The origin of the right coronary artery was ligated in addition to the fenestration and the proximal and distal regions of the coronary artery aneurysm. It has been reported that coronary artery aneurysms are usually asymptomatic and are often discovered by chance during screenings, such as echocardiography, computed tomography, and coronary arteriogram. Here, we report a surgical case of giant right coronary artery aneurysm complicated by acute myocardial infarction.

Detachment of a prosthetic valve due to infective endocarditis caused by Streptococcus pneumoniae.

The incidence of infective endocarditis (IE) due to S pneumoniae has decreased, thanks to antibiotics. However, when it does occur, it can be lethal. The present case provides a reminder of the potential lethality of this postoperative infection.

Regional thigh tissue oxygen saturation during cardiopulmonary bypass predicts acute kidney injury after cardiac surgery.

Cardiopulmonary bypass-associated acute kidney injury may appear postoperatively, but predictive factors are unclear. We investigated the potential of regional tissue oxygen saturation as a predictor of cardiopulmonary bypass-associated acute kidney injury. We analyzed the clinical data of 150 adult patients not on dialysis who underwent elective cardiac surgical procedures during January 2015-March 2017. Near-infrared spectroscopy was used to measure regional oxygen saturation. Sensors were placed on the patients' forehead, abdomen, and thigh. The incidence of acute kidney injury was 2% at the end of surgery, 13% at 24 h, and 9% at 48 h, with the highest at 24 h after surgery. The multiple regression analysis revealed that the thigh regional oximetry during cardiopulmonary bypass, oxygen delivery index, and neutrophil count at the end of cardiopulmonary bypass and surgery were independent risk factors for acute kidney injury. The receiver-operating characteristic curve analysis suggested that a cutoff of regional oxygen saturation at the thigh of ≤ 67% was predictive of acute kidney injury within 24 h after surgery. In conclusion, the regional oxygen saturation at the thigh during cardiopulmonary bypass is a crucial marker to predict postoperative acute kidney injury in adults undergoing cardiac surgery.

[Perioperative Multiple Pulmonary Embolism in a Patient with Giant Right Atrial Myxoma: Report of a Case].

It is reported that 20% of cardiac myxomas are located in the right atrium. An 81-year-old man presented with dyspnea, general fatigue and leg edema lasting for a year. Echocardiography revealed an 80 mm tumor occupying the right atrium and the right ventricle. At surgery, the tumor attached to the atrial septum was removed with the surrounding septal wall. As the tricuspid annulus was dilated, tricuspid annuloplasty with an artificial ring was also carried out. After coming off cardiopulmonary bypass, the patient developed pulmonary hypertension with the pulmonary arterial pressure being 80% of the systemic pressure, which subsided gradually day by day. Histopathological diagnosis was cardiac myxoma. Postoperative lung perfusion scintigraphy revealed postoperative multiple defects. It was considered that multiple tumor embolisms in the distal pulmonary artery caused postoperative pulmonary hypertension. Careful follow-up for remote recurrence would be essential.

Aortic regurgitation due to fibrous strand rupture in the fenestrated left coronary cusp of the tricuspid aortic valve.

Fenestration-related massive aortic regurgitation is rare. The underlying mechanism is reported to be rupture of the fenestrated fibrous strand, and most ruptured cords have been reported in the bicuspid valve or in the right coronary cusp of the tricuspid aortic valve. We encountered a rare case of acute aortic regurgitation due to fibrous strand rupture in the fenestrated left coronary cusp. Preoperative echocardiography detected left coronary cusp prolapse, and operative findings revealed rupture of a fibrous strand in the left coronary cusp. For cases such as this, preoperative echocardiography would be useful for appropriate diagnosis.

[Outcomes of the surgical treatment of infectious endocarditis in a single institute for 13-years].

Recently, due to the progress in patient managements with antibiotics, the prognosis of the active phase infectious endocarditis (IE) has improved, but in some cases, urgent or emergent surgical treatment is inevitable because of the uncontrollable acute heart failure due to valve regurgitation, uncontrollable infection with circulatory collapse, or high embolization risk. We reviewed the outcomes of the 57 IE patients who underwent surgical treatment in our hospital from January, 2000 to April, 2012. Preoperative state including inflammatory responses, bacterial blood culture, antibiotic administration, and surgical procedures were examined. No statistical significances were detected in the mortalities between elective cases (n=43)and urgent or emergent cases (n=14). Totally, mortality was 5.3% including one case in prosthetic valve endocarditis, and was satisfactory.

Aortic arch rerouting and OPCAB in a patient with situs inversus totalis.

Endovascular therapy approaches for aortic aneurysm have lowered the mortality and morbidity rates even in high-risk patients; moreover, these approaches are applied in the management of aortic arch pathologies by transposition of the supra-aortic branches. We present the case of a 75-year-old female patient with situs inversus totalis on hemodialysis. The patient underwent off-pump aortic arch rerouting and thoracic endovascular aortic repair concomitant with coronary artery bypass grafting for distal aortic arch aneurysm and ischemic heart disease.

[Successful treatment of a case of chylothorax, manifesting as a complication following surgical treatment of coarctation of the aorta, by using octreotide acetate; report of a case].

Chylothorax - a serious postoperative complication of thoracic surgery - is associated with high morbidity and mortality, and re-exploration is required in many such cases. A 33-year-old male patient had undergone an extra-anatomic bypass for the treatment of coarctation of the aorta. Persistent chylothorax developed as a complication postoperatively. Octreotide acetate was administered 11 days postoperatively, which resolved the chylothorax without the need for surgical intervention. The patient was discharged from our hospital without any complications at 40 days postoperatively. In the present report, we describe this case and a provide a review of the literature.

Five-week use of a monopivot centrifugal blood pump as a right ventricular assist device in severe dilated cardiomyopathy.

Right heart failure is a critical complication in patients requiring mechanical ventricular support. However, it is often difficult to provide adequate right ventricular support in the acute phase. A 41-year-old woman diagnosed with dilated cardiomyopathy with severe right heart failure underwent implantation of a paracorporeal pulsatile left ventricular assist device (LVAD, Nipro Corporation, Tokyo, Japan) and a MERA monopivot centrifugal pump (Senko Medical Instrument Manufacturing Co., Ltd., Tokyo, Japan) as a right ventricular assist device (RVAD). The patient developed ischemic enteritis 3 weeks after surgery, necessitating fasting and reversal of anticoagulation therapy. A target international normalized ratio of 1.5 was selected, and aspirin administration was discontinued. Following recovery without thromboembolic events, the patient failed the RVAD discontinuation test. Five weeks after surgery, the monopivot centrifugal pump was exchanged for a pulsatile pump. No thrombus was evident on the centrifugal pump. The patient was undergoing cardiac rehabilitation at the time of this writing and awaiting heart transplantation.

Effect of the neutrophil elastase inhibitor sivelestat on perioperative inflammatory response after pediatric heart surgery with cardiopulmonary bypass: a prospective randomized study.

Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response. The neutrophil elastase inhibitor sivelestat is known to suppress this systemic inflammatory response, which can eventually result in acute organ failure. The prophylactic effect of sivelestat on acute lung injury, especially in pediatric cardiac surgery, remains unclear. This prospective double-blind, randomized study evaluated the perioperative prophylactic effect of sivelestat in patients undergoing elective pediatric open heart surgery with CPB. Thirty consecutive patients, weighing 5-10 kg and undergoing open heart surgery with CPB, were assigned to sivelestat (n = 15) or control (n = 15) groups. From CPB initiation to 24 h after surgery, patients in the sivelestat group received a continuous intravenous infusion of 0.2 mg/kg/h sivelestat, whereas patients in the control group received the same volume of 0.9% saline. Blood samples were collected, and levels of interleukin (IL)-6, IL-8, tumor necrosis factor alpha, polymorphonuclear elastase (PMN-E), C-reactive protein (CRP), as well as the white blood cell (WBC) count, platelet count, and neutrophil count (NC) were measured. PMN-E levels, IL-8 levels, WBC count, NC, and CRP levels were significantly lower, and platelet count was significantly higher in the sivelestat group, according to repeated two-way analysis of variance. The activated coagulation time was significantly shorter in the sivelestat group, similarly, blood loss was significantly less in the sivelestat group. In conclusion, Sivelestat attenuates perioperative inflammatory response and clinical outcomes in patients undergoing pediatric heart surgery with CPB.

Moderate prosthesis-patient mismatch may be negligible in elderly patients undergoing conventional aortic valve replacement for aortic stenosis.

Together with aging of the Japanese population, aortic valve replacement (AVR) for aortic stenosis (AS) is now becoming more and more common in the elderly. When the aortic annulus is too small to allow an adequate sized prosthetic valve, aortic root enlargement is required to avoid prosthesis-patient mismatch (PPM). However, age-related comorbidities including aortic root calcification bring significant risk in performing aortic root enlargement. In the present study, 40 patients aged 75 years or more who underwent AVR for AS were reviewed to determine whether moderate PPM has a negative impact on the long-term results. Operative mortality occurred in 2 patients (5%) and moderate PPM occurred in 8 patients. There was no significant difference in survival between cases with and without PPM (P = 0.87). Both aortic pressure gradient (PG) and left ventricular mass index (LVMI) measured by echocardiography were signifi cantly decreased in patients with and without PPM. Reduction of PG was significantly greater in patients with PPM than without PPM (P = 0.02). Reduction of LVMI was not different between the groups (P = 0.58). Moderate PPM did not negatively influence survival or reduction of PG or LVMI in patients aged 75 years or older who underwent AVR for AS.

[Hybrid procedure for combined descending thoracic and abdominal aortic aneurysms].

In patients with previous infrarenal abdominal aortic aneurysm (AAA) repair, the risk of spinal cord ischemia increases after thoracic endovascular aortic repair (TEVAR) for a descending thoracic aortic aneurysm (DTAA). The case is a 67-year-old man with a 60 mm infrarenal AAA and a 73 mm DTAA. We performed the staged hybrid procedure for these aortic aneurysms. First of all we underwent a conventional AAA repair. The bilateral internal iliac arteries and a inferior mesenteric artery were preserved. In addition, the right leg of the tube graft was anastomosed to the right superficial femoral artery to facilitate access of TEVAR. Two months later we performed TEVAR for the DTAA. DTAA extended from the level of the 7th thoracic vertebra to that of the 11th thoracic vertebra. Although there was a certain risk of paraplegia, no complications occurred. The hybrid procedure for combined DTAA and AAA may be a valuable option.

Infectious endocarditis caused by Rhodococcus equi.

Rhodococcus equi is an unusual cause of infection. Furthermore, this infection also tends to be typically described in immunocompromised patients. This report describes a 25-year-old previously healthy man with infectious endocarditis that was found to have been caused by R equi complicated by a subarachnoid hemorrhage, subdural hematoma, and a superior mesenteric artery aneurysm. The patient was successfully treated with antibiotic therapy, followed by a resection of the superior mesenteric artery aneurysm and a repair of the mitral valve.

Successful repair for a giant coronary artery aneurysm with coronary arteriovenous fistula complicated by both right- and left-sided infective endocarditis.

We report a rare case of a 65-year-old woman who underwent an emergent lifesaving heart operation for an undiagnosed right coronary artery aneurysm with a coronary arteriovenous fistula complicated by active infective endocarditis, which affected the aortic valve, mitral valve, and coronary sinus. We performed direct closure of the coronary arteriovenous fistula, ligation of the right coronary artery aneurysm, double coronary artery bypass grafting, and double valvular replacement. Five years after the operation, she had no sign of congestive heart failure or infection, and was not receiving antibiotics.

Adult patent ductus arteriosus: successful surgery with mitral valvuloplasty.

The development of left ventricular dysfunction is a serious complication of longstanding patent ductus arteriosus. An 80-year-old woman who underwent patent ductus arteriosus ligation 13 years previously developed congestive heart failure and mitral regurgitation. She underwent surgical repair with transpulmonary ductus closure and mitral valve annuloplasty under cardiopulmonary bypass. She made a full recovery with improved left ventricular function.

Excision of a cardiac papillary fibroelastoma with the use of a fiberscope.

Cardiac papillary fibroelastoma (CPF) is a histologically benign tumor that can cause a significant embolic event. CPF is usually located on the endocardium, and is found on valves in 90% of cases. We experienced an unusual case of CPF situated on a left ventricular anterolateral papillary muscle. An 84-year-old female who had developed cerebellum infarction five months previously underwent surgical resection of CPF. During surgical resection of the tumor, a fiberscope was useful for detecting the lesion, and allowed us to ensure complete resection with a good surgical view. Our experience encourages us to use the fiberscope when resecting other intracardiac masses, including thrombi.

High-output heart failure caused by arteriovenous fistula long after nephrectomy.

A 70-year-old Japanese woman was admitted to our hospital because of anasarca. At 32 years of age, she had undergone nephrectomy for renal tuberculosis. A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula. Cardiac catheterization disclosed cardiac output of 9.2 l/min and a step-up of oxygen saturation at the renal vein level of the inferior vena cava. Surgical closure of the fistula promptly decreased her cardiac output and improved the heart failure. This is a rare case of an arteriovenous fistula developing long after nephrectomy and causing high-output heart failure.

Determinants of incomplete left ventricular mass regression following aortic valve replacement for aortic stenosis.

OBJECTIVE: Incomplete regression of left ventricular hypertrophy (Abn-LVMI) following AVR for aortic stenosis (AS) may decrease long-term survival. In this prospective study, we identified the predictors of Abn-LVMI. METHODS: Between 1990 and 2000, 529 patients undergoing AVR for AS had clinical and hemodynamic data collected prospectively. Preoperative and annual postoperative transthoracic echos were employed to assess left ventricular mass index (LVMI) and hemodynamics. Abn-LVMI was defined as the 75th percentile of the lowest postoperative LVMI (>128 mg/m2, n = 133). All other patients were included in the normal regression group (N-LVMI). Univariate and multivariable logistic regression analyses were used to determine the predictors of Abn-LVMI. RESULTS: Preoperative hypertension, diabetes, coronary disease, valve size, mean postoperative gradients, effective orifice area, and patient-prosthesis mismatch (PPM, indexed EOA <0.60 cm2/m2) did not predict Abn-LVMI. By logistic regression the most important positive predictor of Abn-LVMI was the extent of preoperative LVMI, with an odds ratio of 37.5 (p < 0.0001). Survival (93.4 +/- 1.8% vs 94.8 +/- 2.3%, p = 0.90) and freedom from NYHA III-IV (75.0 +/- 3.7% vs 76.6 +/- 5.3%, p = 0.60) were similar for both groups at 7 years. CONCLUSIONS: Measures of valve hemodynamics were not important predictors of incomplete regression of hypertrophy. The extent of preoperative hypertrophy was the most important predictor, suggesting that earlier surgical intervention may reduce the extent of hypertrophy postoperatively. Furthermore, the significance of LV hypertrophy to long-term survival must be reassessed, in the absence of scientific evidence.

Contemporary trends in aortic valve surgery: a single centre 10-year clinical experience.

The purpose of this study is to present a comprehensive profile of the trends in aortic valve replacement at a single institution over the past decade. Prospectively collected data concerning 873 patients undergoing aortic valve replacement (AVR), with and without coronary artery bypass grafting (CABG), were analysed. The patients were divided into three time periods: period I, (1990 to 1993); period II, (1994 to 1996); and period III, (1997 to 2000). Actuarial survival of AVR patients with and without CABG at 7 years was 82.9 +/- 2.4% and 79.1 +/- 3.3% (p = 0.17), respectively. Actuarial survival at 7 years for stentless, mechanical, and stented valve patients were 89.5 +/- 2.7%, 85.5 +/- 2.8%, and 76.0 +/- 3.2%, respectively. There was a significant difference in survival between the stentless and stented valve groups (p = 0.014). Age (63.8 +/- 12.9 yrs, 66.2 +/- 11.0 yrs, 67.9 +/- 10.3 yrs; p = 0.01), the incidence of peripheral vascular disease (5.1%, 10.8%, 16.6%; p = 0.001), and the extent of coronary artery disease necessitating CABG (34.0%, 38.8%, 41.0%; p = 0.05) have increased significantly in the later time period. However, operative mortality has remained constant (4.7%, 4.8%, 4.5%; p = 0.9). Moreover, perioperative complications have decreased significantly (27.4%, 18.0, 16.0%; p = 0.001). Multivariate analysis identified more recent time period as independent protective factor for early mortality and morbidity (period I, RR 1.00; period II, RR 0.47; period III, RR 0.40).