David Operation for Insufficient Pulmonary Autograft After Ross-Konno Procedure.

We report the case of a 25-year-old woman who developed severe aortic regurgitation because of pulmonary autograft root dilatation late after Ross-Konno procedure. The geometric heights of all 3 cusps were relatively small, allowing for the David operation with a 24-mm straight graft. We carefully dissected the aortic root and, the dissection process was relatively straightforward, and the basal ring could be sutured properly. The latest follow-up transthoracic echocardiogram showed normal autograft valve function and mild aortic regurgitation. Even in the Ross-Konno procedure, valve-sparing root replacement is possible, as in the Ross procedure.

Mitral endocarditis in hypertrophic obstructive cardiomyopathy with leaflet perforation.

We present a case of mitral endocarditis in hypertrophic obstructive cardiomyopathy with systolic anterior motion of anterior leaflet. Perforated anterior leaflet was repaired and extended septal myectomy was concomitantly performed to control systolic anterior motion and mitral regurgitation.

Very long-term outcomes of twisted auto-pericardial mitral annuloplasty.

OBJECTIVES: During mitral annuloplasty, we twisted the harvested auto-pericardium to enable adequate ring sizing and implanted it to prevent ring-related complications. Indication for twisted auto-pericardial band (APB) was limited to patients with less than severe annular dilation to ensure high reproducibility and durability. The aim of this study was to investigate the long-term outcomes of twisted APB annuloplasty. METHODS: From 1999 to 2009, 107 patients (62 ± 12 years, degenerative 92 and infective endocarditis 15) with isolated posterior mitral leaflet (PML) prolapse with inter-commissural distance of 32 mm or smaller underwent twisted APB annuloplasty. Of these, 104 patients without early leaflet repair failure were studied. Leaflet repairs were predominantly performed by quadrangular resection. Median APB size was 28 mm. RESULTS: Follow-up rate was 98.1% and duration was 10.9 ± 4.8 years. There were two early and 34 late deaths. Survival and freedom from cardiac-related death at 15 years were 61.7% ± 5.6% and 83.8% ± 4.7%, respectively. Age and male sex were independent predictors of mortality. There were four late reoperations for recurrent severe mitral regurgitation (MR), three of which were due to new chordal rupture. Freedom from reoperation and freedom from moderate or severe MR at 15 years were 93.1% ± 3.5% and 81.3% ± 6.2%, respectively. No patients developed hemolysis, ring dehiscence, or infective endocarditis. CONCLUSIONS: The long-term outcomes of twisted APB for isolated PML prolapse without severe annular dilation are satisfactory. Twisted APB annuloplasty may be a preferable option to reduce ring-related complications with sufficient durability.

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.

Long-Term Quality of Life after Cardiac and Thoracic Aortic Surgery for Very Elderly Patients 85 Years or Older.

PURPOSE: We evaluated the outcomes of open heart surgery and long-term quality of life for patients 85 years and older. METHODS: We enrolled 46 patients 85 years and older who underwent cardiac and thoracic aortic surgery between May 1999 and November 2012. Long-term assessment was performed for 43 patients; three patients who died in the hospital were excluded. Patient conditions were assessed before surgery, 6 months and 12 months after surgery, and during the late period regarding the need for nursing care, degree of independent living, and living willingness. RESULTS: Three patients (6.5%) died during hospitalization and 22 (51%) died during the follow-up period. The 1-, 3-, 5-year survival rates were 74%, 49%, and 36%. During the late period, of 21 surviving patients, 18 patients (85%) were living at home. The need for nursing care was comparable before and after surgery. The degree of independent living decreased after surgery. Living willingness was similar before and after surgery. CONCLUSION: Among patients 85 years or older who underwent open heart surgery, 85% were living at home. All patients could perform activities of daily living without any assistance while maintaining living willingness.

Successful repair of mesenteric ischemia in acute type A aortic dissection.

A 64-year-old man with acute type A aortic dissection had superior mesenteric artery occlusion and marked metabolic acidosis. By an emergency laparotomy, bypass grafting from the left external iliac artery to the superior mesenteric artery was performed with great saphenous vein. After deep sedation and antihypertensive management in the intensive care unit, the acidosis resolved, and central repair was carried out. At 10 months postoperatively, his course has been uneventful without mesenteric complications.

Asymptomatic and isolated accessory mitral valve tissue in an adult.

Accessory mitral valve (AMV) tissue is a congenital anomaly that occurs in association with other congenital anomalies, and is an uncommon cause of left ventricular outflow tract obstruction. It is usually detected in early childhood when accompanied by symptoms of obstruction of the left ventricular outflow tract, and is rarely diagnosed in adults. We present a case of a 53-year-old man who was referred to our institution for evaluation of a systolic heart murmur. Echocardiography disclosed a diagnosis of AMV tissue. This case was uncommon because of the lack of severe obstruction of left ventricular outflow, cardiac symptoms, or other cardiac anomalies. We were able to carry out surgical resection of AMV tissue to avert possible progression of aortic insufficiency and the risk of a cerebrovascular embolization. The patient's postoperative course was uneventful, and postoperative echocardiography showed no residual accessory mitral tissue.

Free-floating left atrial ball thrombus after mitral valve replacement with patent coronary artery bypass grafts: successful removal by a right minithoracotomy approach without aortic cross-clamp.

A free-floating thrombus in the left atrium without attachment to either the atrial wall or the mitral valve is extremely rare. We describe a case in a 79-year-old woman with chronic atrial fibrillation and a recent stroke who had undergone mitral valve replacement 25 years previously and coronary artery bypass grafting 5 years previously. Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Median re-sternotomy can be particularly difficult in patients with functioning coronary artery grafts, where the risk of graft injury is a significant concern. Prompt surgical intervention was carried out, and to avoid the challenge of re-sternotomy in this patient with two prior thoracotomies, we successfully removed the thrombus by a right minithoracotomy approach without aortic cross-clamping. There was no postoperative occurrence of a new stroke or aggravation of the pre-existing stroke.

Coronary Artery Pseudoaneurysm due to Medial Mucoid Degeneration Mimicking an Intra-atrial Mass.

Coronary artery aneurysms are frequently asymptomatic and may be difficult to diagnose by cardiac imaging. We herein present a case of a coronary artery aneurysm of the right coronary artery due to medial mucoid degeneration mimicking an intra-atrial mass on echocardiography and magnetic resonance imaging, with the cause being diagnosed after surgery.

[Issues and indications for off-pump coronary artery bypass grafting].

We have evaluated the usefulness of off-pump coronary artery bypass grafting (CABG)[OPCAB]. The subjects were 153 patients who underwent isolated CABG between May 2005 and May 2009. They were divided into 2 groups( on-pump/arrest;ON group:76 subjects vs OPCAB;OFF group:77 subjects). The concomitant conditions, the number of bypasses, the postoperative outcome and the early graft patency rate were compared between the 2 groups. The mean age and the incidence of carotid artery lesions were significantly higher in the OFF group. The number of bypasses was significantly smaller in the OFF group. The postoperative intubation time and the length of postoperative hospitalization were significantly shorter in the OFF group. Concerning major postoperative complications, mediastinitis, cerebral infarction or bleeding was not observed in the OFF group. There was no hospital death in the OFF group. The early graft patency rate with saphenous vein graft (SVG) was significantly lower in the OFF group. Early stage extubation was achieved by the introduction of OPCAB. In some occasions, however, the target site could not be reached with OPCAB, and furthermore, the quality of anastomosis was poor. In order to achieve complete revascularization, therefore, on-pump/arrest surgery should be considered in some cases.

Postoperative elongation of the xiphoid process --report of a case--.

We report a case of a 66-year-old man who presented with an abnormal sensation, tenderness, and pain in the middle of his chest in May 2006, two years after a mitral valve replacement for severe mitral regurgitation and a MAZE operation for chronic atrial fibrillation elective cardiac. He was immediately admitted, and the x-ray examination revealed an abnormal elongation of the xiphoid process. At the time of discharge after the initial operation in 2004, x-rays indicated that the length of the xiphoid process was 3 cm; however, in 2006 it had elongated to 6 cm and was prominent in the anterior view. The patient underwent surgical extirpation of the xiphoid process while he was under local anesthesia. Histological examination of the resected xiphoid process revealed no signs of neoplastic or maligant change. The cause of the elongation of the xiphoid process was believed to be distraction tissue neogenesis. The xiphoid process, which fractured and separated from the sternum at the initial operation, was pulled down inferiorly by the rectus abdominis muscles, following which the xiphoid process became elongated and reconnected with the sternum. In cases of a fractured or amputated xiphoid process after median sternotomy, the xiphoid process should be resected to avoid its neogenesis.

Doppler echocardiographic evaluation of prosthetic valves in tricuspid position.

Doppler echocardiographic characteristics of 29 normally functioning prosthetic valves (23 mechanical, 6 biological) and 8 obstructed mechanical prostheses in the tricuspid position are reported. In normally functioning prostheses, peak velocity, mean pressure gradient, and pressure-half time were 1.25 +/- 0.18 m x sec(-1), 2.6 +/- 1.1 mm Hg, and 122.6 +/- 30.7 msec, respectively. Although no significant differences were seen in peak velocity and mean pressure gradient between mechanical and biological valves, the pressure half-time was significantly greater in biological valves. All normally functioning prostheses had a mean pressure gradient 5.5 mm Hg and pressure half-time < 200 msec. In obstructed bileaflet valves, peak velocity was 1.66 +/- 0.28 m x sec(-1), mean pressure gradient was 6.1 +/- 2.8 mm Hg, and pressure half-time was 265.8 +/- 171.7 msec. These Doppler data were significantly greater than those in normally functioning valves where the mean pressure gradient was 5.1 mm Hg and the pressure half-time was 156 msec in all except one patient. Pathological obstruction of a tricuspid prosthesis can be strongly suspected in patients with a mean pressure gradient > 5.5 mm Hg and a pressure half-time > 200 msec on Doppler echocardiography.

Histological and immunohistological study of cryopreserved aortic valve grafts: the possibility of a clinical application for cryopreserved aortic valve xenograft.

The influence of preservation techniques on xenogeneic immune responses was examined to investigate the possibility of their clinical use. Mongrel dogs and pigs were used as allogeneic and discordant xenogeneic donors of aortic valve grafts, respectively. The allografts and xenografts were implanted in the abdominal aorta of mongrel dogs after cryopreservation or after fresh preservation. Allografts and xenografts were explanted at Days 7 and 42 for histological and immunohistochemical examination. In the fresh preserved allografts and the fresh preserved xenografts, the media of aortic wall grafts were significantly acellular at 7 days. Significant aortic medial destruction and neointimal proliferation with significant destruction of the valve leaflets was observed at 42 days. However, no differences were found among the preservation techniques in the xenogeneic grafts. To alleviate the lack of homografts, approaches such as the tissue-engineered graft may become an alternative in patients who are acceptable candidates.