[Left Ventricular Thrombectomy in Patients with Dilated Cardiomyopathy Accompanied by Cerebral Embolism:Report of Two Cases].

Left ventricular thrombus( LVT) formation is a known complication of ischemic heart diseases including acute myocardial infarction, dilated cardiomyopathy (DCM) and myocarditis. Among them, few cases involve DCM. Two DCM patients with LVT developed acute cerebral infarction and underwent thrombectomy. Both patients presented with sinus rhythm and neither had previous thromboembolic event. However, their transthoracic echocardiography (TTE) showed left ventricular ejection fractions<35% and left ventricular diastolic diameters≥60 mm, indicating high possibilities of LVT formation. The TTE findings suggest that DCM patients require anticoagulation therapy and frequent imaging examination, even with sinus rhythm and no history of thromboembolic events. Once a thromboembolic event occurs, thrombectomy is urgently needed.

[Treatment of Infective Endocarditis with Mitral Valve Plasty Using only Autologous Leaflets by "Washing and Rubbing Method":Report of a Case].

We performed mitral valve plasty( MVP) with vegetation debridement by rubbing with a small gauze ball and by rinsing with saline( named "washing and rubbing method") for mitral regurgitation( MR) due to active infective endocarditis (IE). A 28-year-old male was referred to our hospital with a two-week history of fever. He had renal impairment and anemia, and echocardiography showed severe MR and two vegetations measuring more than 1 cm on the anterior and posterior mitral leaflets( A2-A3 and P2-P3). Severely damaged leaflets were resected and the vegetations were removed by "washing and rubbing method". After the method, treatment by 0.625% glutaraldehyde solution was added to leaflets for its bactericidal and reinforcing effects. MVP using only autologous leaflets was then performed. "Washing and rubbing method" enabled us to avoid using pericardium (autologous/xenogeneic) and/or artificial chordae in infected sites. MVP using "washing and rubbing method" may improve the long-term prognosis of active IE.

[Huge Left Thrombosis after Mitral Valvuloplasty and Maze Procedure;Report of a Case].

Generally, anticoagulation therapy is not essential for patients who maintain sinus rhythm after mitral valvuloplasty. A 66-year-old woman who had undergone mitral valvuloplasty and maze procedure for treatment of mitral valve regurgitation and atrial fibrillation 4 years ago was diagnosed as having left atrial thrombosis despite maintenance of sinus rhythm on electrocardiography. Echocardiography showed narrow mitral valvular area(1.5 cm2), loss of A wave and a huge left atrium. Repeat surgery was performed to replace the mitral valve and to remove the thrombus. The thrombus attached to the posterior wall of the left atrium with a wide basis, and was unrelated to the ablation line of maze procedure. Careful follow-up and anticoagulation therapy should be considered for patients who have a large left atrium and/or rheumatic mitral valve after valvuloplasty even though sinus rhythm is maintained.

Choice of Aortic Valve Prosthesis in a Rapidly Aging and Long-Living Society.

PURPOSE: The aim of this study was to evaluate the long-term results of aortic valve replacement (AVR) with mechanical (M) and bioprosthetic (B) valves as recommended by the Japanese guidelines. METHODS: From April 1995 to March 2014, 366 adult patients underwent AVR. Of these, 127 (35%) patients received M and 239 patients (65%) received B valves. A retrospective analysis of the entire and the selected 124 patients aged 60 to 70 years was carried out. RESULTS: In patients aged 60 to 70 years, the 15-year survival and freedom from reoperation were 88% ± 7% and 100% for the M group and 34% ± 25% (p <0.001) and 73% ± 14% (p = 0.059) for the B group, respectively. Among propensity score matching of the subgroup, there was no significant difference in survival and freedom from reoperation. The rate of thromboembolism was higher in the M (M: 0.58% vs B: 0.35% patient per year, p <0.001) and the rate of hemorrhage was higher in the M group (M: 0.34% vs B: 0.12% patient per year, p <0.001). CONCLUSION: The current strategy of aortic valve choice based on the Japanese guidelines has provided excellent long-term results so far.

[Atrial Septal Defect with Hereditary Deficiency of Antithrombin III].

A 41-year-old female with hereditary deficiency of antithrombin III (ATIII) was diagnosed with atrial septal defect( ASD) and scheduled for the closure of ASD. She had been taking warfarin since she suffered from deep vein thrombosis 10 years ago. Preoperative management of anticoagulation included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and closure of ASD was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until prothrombin time-international normalized ratio(PT-INR) recovered to around 2.5 with warfarin. Her intra-and postoperative courses did not show any thromboembolic events, and she was discharged 20 days after the surgery.

Distal aortic arch aneurysm associated with persistent fifth aortic arch.

Persistent fifth aortic arch (PFAA) associated with interruption of the fourth aortic arch is a rare malformation, usually requiring surgical intervention in childhood. A 51-year-old woman developed a distal aortic arch aneurysm associated with PFAA after patch aortoplasty for coarctation of the aorta at the age of 18. To our knowledge, this is the first reported case of a distal aortic arch aneurysm associated with PFAA. Residual tissues of the ductus and PFAA, which is not a definitive aortic arch, and the implanted synthetic patch may have been related to the development of the aneurysm. Graft interposition between the proximal border of PFAA and the descending aorta was performed because severe adhesions impeded the application of the fourth aortic arch as a proximal anastomotic site of the graft. Accurate diagnosis and sufficient understanding of PFAA allow an appropriate surgical treatment in childhood with a good result over the long term.