A surgical case of infected cardiac myxoma.

A 60-year-old woman presented with a fever of unknown origin. Echocardiography revealed a large left atrial tumor protruding into the left ventricle during diastole. Laboratory investigation showed an elevated white blood cell count, C-reactive protein concentration, and interleukin-6 concentration. Magnetic resonance imaging showed hyperacute microinfarcts and multiple old lacunar infarcts. Surgery was performed under suspicion of cardiac myxoma. A dark red jelly-like tumor with an irregular surface was removed. Histopathological examination revealed cardiac myxoma, the surface of which was covered with fibrin and bacterial masses. Preoperative blood culture was positive for Streptococcus vestibularis. These findings were compatible with a diagnosis of infected cardiac myxoma. We used an antibiotic therapeutic regimen for infective endocarditis, and the patient was discharged home on postoperative day 31. Prompt diagnosis and treatment, including effective and efficient antibiotic therapy and complete tumor resection, increased the chance of a better outcome in patients with infected cardiac myxoma.

Comprehensive Pain Control Strategy in Minimally Invasive Mitral Valve Repair.

PURPOSE: The effect of our comprehensive strategy to reduce pain after minimally invasive mitral valve repair through a right mini-thoracotomy was assessed retrospectively. METHODS: Our comprehensive strategy constituted the following: planned rib cutting to avoid rib injury, sufficient intercostal muscle division to mobilize the cut rib, limiting the number of intercostal ports, avoiding nerve entrapment, continuous extra-pleural intercostal nerve block, and regular use of oral non-steroidal anti-inflammatory drugs. We compared patients treated with this comprehensive strategy (Group S, n = 13) and patients before this strategy was implemented (Group C, n = 13). We used a numerical rating scale (NRS) as a pain scale during the first 3 days postoperatively. RESULTS: The average NRS was significantly lower in Group S (0.82 ± 0.49) than in Group C (2.40 ± 1.46) (P <0.01). The maximum NRS was also significantly lower in Group S (3.23 ± 1.17) than in Group C (5.69 ± 2.43) (P <0.01). The number of patients using additional single-dose analgesic were significantly less in Group S (23.1%) than in Group C (84.6%) (P <0.01). CONCLUSION: Our comprehensive pain control strategy effectively reduced postoperative pain in minimally invasive mitral valve repair.

Utility of Ultrasonographic Assessment of Distal Femoral Arterial Flow during Minimally Invasive Valve Surgery.

PURPOSE: To evaluate the utility of ultrasonographic assessment of blood flow to the lower limb below the cannulation site in minimally invasive cardiac surgery (MICS). METHODS: Twenty-two patients who underwent ultrasonographic assessment in MICS were reviewed retrospectively. In all patients, the right femoral artery was used for arterial cannulation. Ultrasonographic assessment was performed using a 15-MHz ultrasonography small probe, and regional oxygen saturation was monitored by near-infrared spectroscopy (NIRS). RESULTS: The mean flow velocity at the distal side of the cannulation site was 46.2 ± 25.4 cm/s. In six patients, a >40% decreased from baseline regional oxygen saturation was observed. In five of the six patients, the flow velocity was very slow, and spontaneous echo contrast was also observed in three cases. Their regional oxygen saturation was improved rapidly after distal leg perfusion. In the remaining case, the flow velocity was not decreased. In another one case, the stenosis at the cannulation site was detected after decannulation and repaired immediately. No limb ischemic complications were observed in this series. CONCLUSION: Ultrasonographic assessment combined with the NIRS monitoring is useful to prevent lower limb ischemic complications after femoral arterial cannulation in MICS.

Trunk Muscle Cross-Sectional Area as a Predictive Factor for Length of Postoperative Hospitalization after Surgical Aortic Valve Replacement.

PURPOSE: We investigated the utility of trunk muscle cross-sectional area to predict length of hospitalization after surgical aortic valve replacement (AVR) for aortic stenosis (AS). METHODS: Adult AS patients who underwent isolated AVR at a single institution were studied. The cross-sectional area of the erector spinae muscles (ESM) at the first and second lumbar vertebrae and that of the psoas muscle (PM) at the third and fourth lumbar vertebrae were measured on preoperative computed tomography (CT). Each was indexed to body surface area. Risk factors for prolonged postoperative hospitalization (>3 weeks) were assessed using multivariate regression analyses. RESULTS: Of 56 patients (mean age 76 ± 9 years; 25 men), 20 (35.7%) patients required prolonged hospitalization. A smaller indexed ESM cross-sectional area at the first lumbar vertebra (per 1 cm/m2, odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.57-0.88, P <0.01) and lower preoperative serum albumin level (per 0.1 g/dL, OR = 0.83, 95% CI = 0.70-0.99, P <0.05) were shown as independent predictors. Indexed PM cross-sectional area was not statistically significant. CONCLUSION: The cross-sectional area of the trunk muscles can be used to identify patients at risk for prolonged hospitalization after AVR for adult AS.

Commissure enhancement technique in aortic valve repair.

Sinotubular junction enlargement is one of possible causes of aortic valve regurgitation. However, there is no appropriate technique for sinotubular junction diameter reduction in aortic valve repair in a patient without disease of the ascending aorta or sinus of Valsalva. Herein, we report a simple commissure enhancement technique comprising the placement a horizontal mattress suture buttressed with felt at the sinotubular junction level in the commissure area. This technique results in the relocation of the commissure to the inner side, and a reduction in the diameter of the sinotubular junction.

Usefulness of Left Atrial Volume as an Independent Predictor of Development of Heart Failure in Patients With Atrial Fibrillation.

Left atrial (LA) volume is known as a robust predictor of heart failure (HF) development in patients with sinus rhythm. However, among patients with atrial fibrillation (AF), the utility of LA volume for prediction of HF development has not been determined. The objective of this study was to investigate the utility of LA volume for prediction of HF development in patients with AF. Among adult patients who were referred for transthoracic echocardiography, those with AF at the baseline echocardiography were included and prospectively followed up to new-onset HF events. Patients who had significant valvular heart disease, congenital heart disease, or reduced left ventricular (LV) ejection fraction were excluded. Cox-proportional hazards models were used to assess the risk of HF development. Of a total of 562 patients, 422 (mean age 69.6 ± 9.7 years, 66.1% men) met study criteria, and 52 (12.3%) developed HF during a mean follow-up of 55 ± 43 months. Patients with HF events had larger indexed LA volume, compared with those without HF events (69 ± 46 vs 50 ± 23 ml/m2, p <0.0001). In a multivariable analysis adjusted for other co-morbidities, LA volume was a significant predictor for HF development [per 10 ml/m2; hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.06 to 1.22, p <0.001], independently of age (per 10 years; HR 1.71, 95% CI 1.16 to 2.52, p <0.01), LV ejection fraction (per 10%; HR 0.67, 95% CI 0.52 to 0.86, p <0.01), and indexed LV mass (per 10 g/m2; HR 1.13, 95% CI 1.03 to 1.24, p <0.05). Also, LA volume had an incremental effect for prediction of HF development to these conventional risk factors (p <0.0001). In conclusion, LA volume provides prognostic information for the prediction of future HF events in patients with AF.

New Flexible Internal Annular Fixation Rings for Tricuspid Aortic Valves.

OBJECTIVES: Although aortic annulus repair has a long history, there are still no ideal devices to control an aortic annulus. We have developed a new method involving the use of an expanded polytetrafluoroethylene graft with the support of a metallic ring holder during implantation from inside an aorta, with no dissection of the surrounding aortic annulus. METHODS: We used aortic annular rings of 18 to 24 mm made of Gore-Tex tubed grafts (W.L. Gore & Associates, Flagstaff, AZ, USA) and metallic ring holder. After cutting the graft circumferentially to a 5-mm thickness, it was compressed manually to decrease the thickness. Then, a metallic ring holder corresponding to the graft size was inserted into the graft. The metallic ring holder was fixed to the graft with one 4-0 monofilament suture using 6 holes and the side trench on the metallic ring holder. The proper size for the graft was determined, and the appropriate annuloplasty ring was selected. A row of 4-0 double-needle braided sutures with expanded polytetrafluoroethylene spaghettis was sewn from the aortic side into the left ventricular outflow tract with a horizontal mattress stitch. After all sutures around the annulus were placed, they were tied down and the metallic ring holder was removed. The leaflets were repaired if necessary. RESULTS: A total of 9 patients with tricuspid aortic valve have undergone this procedure since January 2015. The sizes of the aortic annular rings were 20 mm ( n = 3), 22 mm ( n = 5), and 24 mm ( n = 2). Aortic leaflets were repaired in 6 patients (6 central plications). Concomitant procedures were total aortic arch replacement ( n = 2), mitral valve repair ( n = 2), tricuspid valve repair ( n = 1), and coronary artery bypass grafting ( n = 2). There were no hospital deaths and no major morbidities. All patients were checked for mild or less than mild aortic regurgitation during the mean follow-up period of 13 months. Postoperative echocardiograms showed excellent peak pressure gradients compared with preoperative echocardiograms. Postoperative cardiac computed tomography scans were performed in 6 patients. The discrepancies between the ring size used and postoperative annular size were <1-mm diameter in all patients. CONCLUSIONS: This new flexible ring is easy to use to fix an aortic annulus from the inside. Early results reveal excellent control of aortic regurgitation with the projected annular size. Further investigations are needed to ensure the effectiveness of the ring.

Infective Endocarditis on Caseous Calcification of the Mitral Annulus Involving Both the Anterior and Posterior Annulus: A Rare Case Report.

A 72-year-old man with end-stage renal disease and who was on dialysis was admitted with fever and chills. Two years previously, he had been diagnosed with caseous calcification of the mitral annulus (CCMA). Blood cultures revealed Staphylococcus aureus, and echocardiography revealed vegetation attached to the CCMA lesion, progressing to both the anterior and posterior annulus. Infective endocarditis (IE) was diagnosed and antibiotic (ampicillin) treatment was initiated. Emergent mitral valve replacement was performed after the occurrence of multiple cerebral infarctions. During surgery, we identified vegetation attached to the CCMA lesion. After surgery, the patient showed a good recovery and was discharged. This case demonstrates that IE can be complicated with CCMA.

Posterior leaflet reconstruction using autologous pericardium in mitral repair.

A 75-year-old woman experienced recurrent mitral regurgitation caused mainly by a shrunken and tethered posterior mitral leaflet with a dilated left ventricle. Posterior leaflet motion was severely restricted. We successfully resolved the tethering and restored valve coaptation and competence using posterior leaflet reconstruction, which is a modified method of posterior leaflet augmentation using autologous pericardium. This technique can recover the posterior leaflet function by improving tissue volume and tethering.

Challenging mitral valve repair for double-orifice mitral valve with noncompaction of left ventricular myocardium.

Double-orifice mitral valve (DOMV) is a relatively rare cardiac anomaly. Although usually associated with various cardiac anomalies, co-presence of DOMV and noncompaction of left ventricular myocardium (NCLVM) is extremely rare. Here, we present a 24-year-old male who underwent mitral valve repair using artificial chordae and annuloplasty at the posterior commissure for severe mitral regurgitation (MR), resulting from flail anterior leaflet of the larger postero-medial orifice and dilatation of left ventricle with NCLVM. One year later, he underwent second mitral valve repair for recurrence of MR. Further endoscopic evaluation of the left ventricle, and reinforcement via artificial ring, enabled us to achieve repair.

Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva in a Young Athlete.

Cardiac events associated with congenital coronary abnormalities are rare but potentially life-threatening in a young population. Most of these patients are not diagnosed before their initial cardiac event. Amongst such coronary artery anomalies, sudden death is frequently seen in an anomalous origination of a coronary artery from the opposite sinus. We herein present the case of a patient who presented with sudden cardiac arrest associated with an anomalous right coronary artery originating from the left sinus of Valsalva. Surgical treatment was selected because there was evidence of reversible ischemia based on the findings of a stress test.

Tricuspidization and reimplantation procedure for unicuspid aortic valve with annuloaortic ectasia.

Unicuspid aortic valve is a rare anomaly. We report 2 cases of successfully treated unicuspid valves with aortic dilatations by using a tricuspidization and reimplantation procedure. Two men, 35 and 39 years old, with severe aortic regurgitation and stenosis received this procedure. The sclerotic portion of a unicuspid valve, including 2 rudimentary commissures, was resected and reconstructed with autologous pericardium to create a tricuspid valve. An aortic root was replaced with a prosthetic graft. Postoperative echocardiogram showed trivial aortic regurgitation and minimal pressure gradient. Follow-up was 32 and 34 months, respectively. These valves remained stable in these periods. Tricuspidization and reimplantation is a promising procedure.

Endograft infection after hybrid surgery for chronic Stanford type B aortic dissection: endograft infection and treatment.

While the incidence of endograft infection is very low, the treatment is difficult when it occurs. We herein present the case of a 52-year-old male who had undergone a graft replacement in the proximal descending thoracic aorta for dissected aortic aneurysm (DA) 6 years previously and hybrid surgery 2 years previously, which consisted of an abdominal graft replacement, visceral and renal debranching surgery and endovascular surgery for a ruptured abdominal DA and residual thoracoabdominal DA. Following collapse from septic shock due to an endograft infection, we performed an in situ reconstruction of the entire thoracoabdominal aorta following intensive antibiotic therapy and 2 preoperative CT-guided percutaneous interventions. He was discharged 4 weeks after the surgery without any complications.

Massive pulmonary embolism with liver injury associated with chest compressions during cardiac resuscitation.

A 34-year-old man was admitted to our hospital because of sudden respiratory failure caused by massive pulmonary embolism. After arrival in the hospital, the patient experienced cardiopulmonary arrest, and we promptly initiated percutaneous cardiopulmonary support, in addition to sternal compressions for cardiopulmonary resuscitation. Computed tomography revealed massive pulmonary embolisms and intraperitoneal bleeding due to liver injury. After interventional hemostasis of the hepatic arteries, we performed emergent pulmonary embolectomy and hemostasis of the liver with gauze packing. Absence of further intraperitoneal bleeding was confirmed 2 days later on a second look. The patient was discharged 2 month later without neurologic sequelae.

Hybrid surgery for intralobar pulmonary sequestration with aortic aneurysm.

A 62-year-old man with past history of chronic atrial fibrillation, congestive heart failure, and pneumonia was referred to our hospital for further workup of pulmonary sequestration. Enhanced computed tomography revealed intralobar pulmonary sequestration (IPS) of the lower left lobe, as well as aortic aneurysmal dilation at the origin of the aberrant feeding artery. We performed a hybrid operation consisting of thoracic endovascular aortic repair and excision of the IPS and left lower lobe by video-assisted thoracic surgery. The patient was discharged 5 days later without complications.

Valve-sparing root replacement surgery for the truncal valve in an adult: report of the initial successful case.

We describe here an initial successful case of valve-sparing surgery using reimplantation technique in a 24-year-old male with aortic root dilatation with truncal valve insufficiency after common arterial trunk repair. Concomitant right ventricular outflow tract reconstruction with expanded polytetrafluoroethylene was also successfully performed. He was discharged home on postoperative day 10 without stenosis or regurgitation of repaired valves. He is in New York Heart Association class I condition without any anticoagulant agents 6 months after operation. Of course, careful follow-up will be needed though our early result is acceptable.

Commissure avulsion of the aortic valve caused by purulent pericarditis: report of a case.

A 20-year-old man with fever and chest pain was referred to our hospital, where purulent pericarditis was confirmed by various examinations. Hemodynamic collapse and acute pulmonary edema occurred 1 week later, caused by acute severe aortic valvular regurgitation (AR). Emergency surgery revealed that the AR had been caused by avulsion of the aortic valvular commissure, which seemed to have resulted from penetration of the pericardial inflammatory process to the aortic root. We report this case because purulent pericarditis is now relatively uncommon and resultant aortic commissure avulsion is even rarer.

Thromboembolism in a patient with a mechanical mitral valve during anticoagulation with dabigatran etexilate.

Recently, several new anticoagulants have been used instead of warfarin for preventing thromboembolism. In the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial, the direct thrombin inhibitor dabigatran etexilate was as an effective and safe as dose-adjusted warfarin for prevention of stroke in high-risk patients with atrial fibrillation. However, the safety and efficacy of thromboprophylaxis after mechanical valve replacement is uncertain. We report a 57-year-old man with a mechanical heart valve who experienced acute upper limb thromboembolism during dabigatran intake. Dabigatran might be inadequate for thromboprophylaxis after mechanical valve replacement.