[Mid-ventricular Hypertrophic Obstructive Cardiomyopathy in a Patient Whose Hemodynamics Were Exacerbated by Forward Shift of the Posterior Leaflet Caused by Mitral Annular Calcification].

A 82-year-old woman came to our hospital because of orthopnea and cardiac cachexia. Echocardiography revealed a pressure gradient of 50 mmHg at the left ventricular outflow tract and that of 78 mmHg at the mid-ventricle. Systolic anterior motion of the mitral leaflet caused by mitral annular calcification and severe mitral regurgitation( MR) were observed. On the basis of the patient's age and poor general conditions, we resected abnormal myocardium on the septum from the outflow tract down to the apex via aortic valve and we left the mitral annular calcification. The pressure gradient in the left ventricle, systolic anterior motion and mitral regurgitation were relieved, and her postoperative course was uneventful. Two years after the surgery, she remains in New York Heart Association( NYHA) class Ⅰ and is well.

[Mitral Valve Plasty for Complicated Lesions with Barlow-like Anterior Leaflet].

A 66 year-old male was admitted to our clinic suffering from dyspnea on effort. Cardio thoracic ratio (CTR) was 62%. Electrocardiogram showed atrial fibrillation. Echocardiogram showed severe mitral regurgitation (MR), Barlow like billowing and thickened A2 and A3, and loss of P2 and P3. Operation was performed through median sternotomy and right sided left atrial incision. Left atrial appendage was closed with running suture. Maze operation was done. Triangular resection of A2 and A3 was done. P2 and P3 were adhered to the left ventricular wall. First we cut the adhered posterior leaflet in a shape of inverted T. And the adhered leaflet was dissected from the left ventricle by the scissors. The detached annulus was mattress-sutured with a pledgetted suture. The leaflets were sutured together, then a new posterior leaflet was remade using mitral valve leaflet tissue and the shape became higher and round. Post operatively, MR was none, and posterior leaflet functioned well. Sinus rhythm was recovered. Eleven years later, no MR and sinus rhythm were shown.

[How to Repair the Bicuspid Aortic Valve Accompanying Regurgitation?]

We repaired the bicuspid aoric valve( BAV) with aortic regurgitation( AR) by bicuspidization. However, repaired fused cusp does not open full, and shows doming. Between 1997 and 2023 we repaired 30 BAV with AR. Mean Age was 44( 15-79) years old. Male gender was 26/30. Between 1997 and 2017, we repaired by triangular resection and cusp suspension or central plication and the commissural positions remained as it was, in 17 cases. Between 2018 and 2023, we repaired by triangular resection and aortic root remodeling to make the commissure angle 180 degree in 13 cases. One patient died because of compression occlusion of left main trunk by Schaefer's annulplasty suture post-operatively. Postoperative aortic valve pressure gradient was 12.2±5.4 mmHg in natural commissure position group, 14.7±6.8 mmHg in the 180 degree commissure position group( p=0.37). And in the 180 degree commissure position group, the fused cusp did not show doming. In the 180 degree commissure position group, the fused cusp did not show doming. However, trans aortic valve pressure gradient did not decrease. On the other hand, in the natural commissure group, the fused cusp showed doming. However, the valves well functioned up to 25 years without aortic stenosis.

Transmitral thrombectomy to treat a patient with Takotsubo cardiomyopathy.

A 68-year-old woman with a history of bipolar disorder was admitted to another hospital with a gastric ulcer. On admission, Takotsubo cardiomyopathy was suspected because her electrocardiogram was abnormal and the characteristic left ventricular wall motion was apparent. On hospital day 11, echocardiography revealed a thrombus in the apex of the left ventricle. She was transferred to our hospital and heparin treatment was commenced. On follow-up echocardiography, the left ventricular wall motion had normalized but thrombus mobility had increased. Thrombectomy was performed via a transmitral approach with endoscopic assistance. Endoscopy allowed excellent visualization of the intracardiac structure.

A nationwide survey of aortic valve surgery in Japan: current status of valve preservation in cases with aortic regurgitation.

OBJECTIVE: Although aortic valve-sparing operations are performed throughout Japan, the indications, specific repair techniques, and outcomes have not been reported in full. Thus, we conducted the first nationwide survey of aortic valve-sparing surgery. METHODS: We mailed a questionnaire to 508 institutions across Japan to obtain information on elective aortic valve and aortic root surgeries performed in 2014. Included in the mailing was a secondary questionnaire that sought further information from institutions reporting aortic valve-sparing surgeries. RESULTS: Two hundred and fifty (49%) institutions responded and reported a total of 7859 aortic valve operations and 771 aortic root operations. Aortic valve operations performed strictly for aortic regurgitation totaled 2080, 156 (8%) of which were aortic valve repairs. Of the 699 aortic root surgeries performed for aortic regurgitation, 236 (34%) were valve-sparing root replacement surgeries. The valve-sparing root replacement surgeries comprised aortic valve reimplantation (n = 173, 73%) and aortic root remodeling (n = 63, 27%). Five of 57 (9%) institutions were responsible for 42% (99/233) of the total aortic valve-sparing surgeries performed. Detailed information that was obtained for 233 patients who underwent aortic valve repair or valve-sparing root replacement showed 30-day mortality and reoperation for regurgitation after aortic valve repair (n = 97), aortic root remodeling (n = 37), and aortic valve reimplantation (n = 99) to be 1, 0, and 1% and 3, 3, and 1%, respectively. CONCLUSION: To date, aortic valve-sparing operations have been performed for limited patients at limited institution in Japan, but the early outcomes have been excellent.

Total endoscopic repair of unroofed coronary sinus syndrome via right mini-thoracotomy.

Unroofed coronary sinus syndrome (URCS) is a rare congenital cardiac anomaly. Recently, cardiac surgery using a minimally invasive approach has become the preferred treatment, affording better cosmetic results and a more rapid post-operative recovery than the traditional method. We report the case of a 54-year-old male in whom partial URCS was treated via a totally endoscopic repair technique featuring right mini-thoracotomy.

Interrupted commissural band annuloplasty prevents mitral stenosis.

BACKGROUND: Mitral annuloplasty is an important component of the treatment of degenerative mitral valve disease. However, postoperative echocardiography reveals elevated mitral gradients in some patients. We developed a technique that we termed interrupted commissural band annuloplasty (iCBA), which does not shorten either the anterior or posterior annulus and is not associated with the development of a mitral gradient. We compared the echocardiographic characteristics of patients treated using this method versus Cosgrove ring (COS) placement, both at rest and during exercise. METHODS: ICBA features placement of three sutures in the commissures using two bands and shortens the commissural annular length by 60 %. We used this method to treat 63 patients and placed Cosgrove bands in 58. Of all patients, 48 who underwent iCBA and 34 with COSs passed the exercise echocardiographic test. RESULTS: The maximal transmitral pressures at rest in the iCBA and Cosgrove groups were 8.04 ± 0.74 and 11.30 ± 0.88 mmHg (P = 0.0029), respectively, and the mean transmitral pressures at rest were 2.46 ± 0.74 and 3.61 ± 0.32 mmHg (P = 0.0037), respectively. The maximal transmitral pressures during exercise were 11.79 ± 0.97 and 18.37 ± 1.16 mmHg (P < 0.0001), and the mean transmitral pressures during exercise were 4.95 ± 0.45 and 7.76 ± 0.53 mmHg (P < 0.0001). CONCLUSIONS: ICBA prevents postoperative mitral stenosis both at rest and importantly during exercise.

An improved isolation technique for shaggy brachiocephalic artery and aortic arch replacement.

A mobile plaque in the ascending and transverse aorta increases the risk of cerebral infarction during treatment of an arch aneurysm. A previous report described an isolation technique for replacing the ascending and transverse aorta with a mobile atheroma by selective hypothermic antegrade cerebral perfusion (Shiiya et al., Ann Thorac Surg 72:1401-1402, 2001). Here, we present an improved isolation technique for more severe conditions, such as shaggy aorta and shaggy brachiocephalic artery, in two patients. First, we anastomosed both axillae arteries with grafts and placed drainage cannulae in the superior and inferior venae cavae prior to filling the cardio-pulmonary bypass system with blood. Next, we cannulated the right common carotid artery and selective cerebral perfusion was started prior to cannulation and perfusion of the left common carotid artery. Systemic perfusion was then initiated through the axillae grafts. Both patients who underwent this procedure recovered without neurologic complications.

Controversy in mitral valve repair, resection or chordal replacement?

Mitral valve plasty has superseded valve replacement as the standard technique for treating degenerative mitral valve prolapse. Quadrangular resection is considered the gold standard for posterior leaflet prolapse. Chordal replacement was first developed to treat the anterior leaflet and subsequently became widely used for the posterior leaflet, after which a new version of posterior leaflet resection was developed that did not involve local annular plication. In the era of the mini-thoracotomy, the premeasured loop technique is simple to adopt and is as durable as quadrangular resection. However, there is controversy surrounding whether resection or chordal replacement is the optimal technique. The resection technique is curative because it removes the main pathologic lesion. The disadvantage of the resection is that it can be complicated and often requires advanced surgical skills. In contrast, chordal replacement is not pathologically curative because it leaves behind a redundant leaflet. However, the long-term results appear to be equivalent in many reports. Functionally, chordal replacement retains greater posterior leaflet motion with a lower trans-mitral pressure gradient than quadrangular resection. Moreover, chordal replacement is simple and yields uniform results. The optimal technique depends on whether the anterior leaflet or posterior leaflet is involved, the Barlow or non-Barlow disease state, and whether a mini-thoracotomy or standard sternotomy approach is used. For mitral valve repair, the most superior and reliable technique for the posterior leaflet is resection using the newer resection technique with a sternotomy approach, which requires a skilled surgeon.

Interrupted commissural band annuloplasty for degenerative mitral valve disease.

BACKGROUND: Mitral annuloplasty is useful for treating degenerative mitral valve disease. Although the incidence of complications is low, prosthetic ring-related complications can occur. Hemolysis and mitral stenosis are serious complications requiring reoperation. Limited use of prosthetic material could decrease the risk for complications. Commissural annuloplasty has been reported by Kay and Reed; their techniques involve suture plication. To prevent dehiscence, we selected short bands and compared the echocardiographic changes between this method and the Cosgrove ring. METHODS: Three sutures are placed in the commissures using two bands, which shortens the annular length by 60%. We performed this interrupted commissural band annuloplasty (iCBA) in 63 patients and used Cosgrove bands for 58 patients. RESULTS: Clinically, for iCBA and Cosgrove groups, respectively, hemolysis with mild mitral regurgitation occurred in 0 and 2 cases (p=0.084), and mitral stenosis due to pannus formation occurred in 0 and 1 case (p=0.224). There was a trend toward a lower ring-related complication rate in the iCBA group. On echocardiography, for the iCBA and Cosgrove groups, respectively, the maximum anterior-posterior distance of the annulus in diastole was 3.1±0.7 mm and 2.6±0.4 mm (p<0.001), maximum opening angle of the posterior leaflet was 85.7±17.3 degrees and 103.4±20.1 degrees (p<0.001), and coaptation distance was 11.6±3.7 mm and 8.4±2.6 mm (p<0.001). CONCLUSIONS: The iCBA method prevented posterior leaflet tethering, kept the coaptation distance deep on echocardiography, and was associated with lower trends of ring-related complications. Because the posterior side of the annulus was not reconstructed, iCBA is suitable for fibroelastic deficiency, rather than for Barlow's disease.

Aggressive atrial volume reduction for bilateral giant atria improves respiratory function.

Giant bilateral atria with mitral and tricuspid regurgitation can cause postoperative respiratory dysfunction. In this article, we describe a case of giant atria with poor respiratory function that was improved by atrial volume reduction. A 79-year-old woman was referred to our institution for valve surgery. Her vital capacity was 1,080 mL. The mitral and tricuspid valves were repaired during surgery. We removed a circular section of the left atrial wall. The right atrial wall and interatrial septum were removed; this improved her vital capacity to 1,370 mL. We conclude that aggressive volume reduction of both atria improves respiratory function.

Double triangular resection for a widely prolapsed posterior mitral leaflet.

A wide and redundant prolapse of the posterior mitral leaflet in active infective endocarditis cannot be easily repaired. A sliding plasty can be attempted, but the range of annular plication is often too large. Chordal replacement is another option, but is prone to long-term degeneration because the redundant leaflet still exists. Here, we describe a simple resection technique that utilizes only two small triangular resections. The resections are sutured with no need to shorten the annulus. The leaflet tissue between the two triangular resections must be preserved to make an appropriately shaped posterior leaflet.

Hourglass-shaped resection technique for repair of tall mitral valve posterior leaflet prolapse.

OBJECTIVE: We developed a repair technique for an excessively high posterior leaflet of the mitral valve. This is an improvement of the folding plasty. METHODS: The resection shape is that of an hourglass rather than a quadrangle. The vertical sides of the quadrangle curve inward, which helps to prevent the curtain effect or restriction that is common in the large triangular resection or folding plasty. We used hourglass resection for 26 tall posterior leaflets (53.8% were Barlow disease) and triangular resection for 23 posterior leaflets of normal height (without Barlow disease). RESULTS: All surgeries were performed successfully. There was no mortality, no mitral regurgitation greater than moderate, and no systolic anterior motion of the anterior leaflet in the early postoperative period. One patient required a second pump run, and another required a second repair procedure. The mean follow-up period was 2.3 years (0.3-4.9 years) for the hourglass resection and 2.8 years (0.1-4.9 years) for the triangular resection. One patient in the triangular resection group died of rectal cancer. One patient treated with the hourglass resection via minithoracotomy required re-repair 1 month postoperatively due to suture dehiscence. For the hourglass and triangular resection groups, the most recent postoperative echocardiogram revealed no mitral regurgitation in 18 and 20 cases, respectively; mild mitral regurgitation in 7 and 3 cases, respectively; and moderate mitral regurgitation in 1 and 0 cases, respectively. CONCLUSIONS: The short-term results of our strategy for posterior leaflet repair appear promising.

[New concept of mitral valve repair for posterior leaflet prolapse].

BACKGROUND: Conventional repair of posterior mitral valve prolapse involves quadrangular resection and sliding plasty. However, these 2 methods require annular plication and useful leaflet tissue is sacrificed. METHODS: Our concept is to make an ideally shaped posterior leaflet without annular plication. When the leaflet is not high, we select triangular resection( TRR). For a high leaflet, we developed hourglass resection (HGR). The hourglass shape consists of 2 triangles:the upper inverted triangle is resected and the lower triangle is resected and sutured to the annulus. From 2007 to 2012, 65 patients with mitral regurgitation (MR) with leaflet prolapse were repaired. 49 patients who had posterior leaflet prolapse were analized in this study. The mean age was 61.7±11.5 years and 67.3% were men. RESULTS: All patients underwent successful repair. There were no hospital deaths, or no systolic anterior motion. In 1 patient, repair was repeated 1 month post-operatively. The mean follow-up period was 2.6±1.5 (0.1 ~ 4.9) years. There were no late deaths. The most recent echocardiogram revealed no MR in 36, mild MR in 12, and moderate MR in 1 cases. CONCLUSION: The short-term results of our strategy for posterior leaflet repair are good.

A single papillary muscle with chordal rupture in an adult.

A single papillary muscle (SPM) is a rare anomaly in normal adults. It is sometimes associated with a complete common atrioventricular canal. Chordal rupture combined with a single papillary muscle in an adult has not been reported. We repaired the mitral valve with chordal replacement, although this was technically difficult, because the decision to place an artificial chordal attachment on the papillary muscle plays an important role. This report presents successful chordal replacement and band annuloplasty in a case of chordal rupture with a single papillary muscle. A surgical tip for chordal replacement with a single papillary muscle is to suture artificial chords on the same side of the SPM head as the affected side of the mitral valve, considering the direction of pull of the artificial chords.

Giant sinus of valsalva aneurysm with severe aortic incompetence treated with a valve-sparing operation.

Typically, a sinus of Valsalva aneurysm with severe aortic incompetence is repaired with patch closure and aortic valve replacement. Here, we describe a very rare case of a giant nonruptured right Valsalva aneurysm, combined with severe aortic incompetence, treated with a valve-sparing aortic root replacement. During surgery we noted that the lengths of the free margin of the cusps and annuli were not uniform. As a result, we placed the first layer of sutures for the Valsalva graft in the same ratio as the annuli. It is difficult to preserve the geometry of the aortic annulus and position the commissures in the graft. One surgical tip for valve-sparing aortic root replacement for a sinus of Valsalva aneurysm with severe aortic incompetence is to suture the commissures inside the graft in the same ratio as the length of the cusp free margins.

Chordal replacement for leaflet prolapse in a posterior mitral valve with a calcified mitral annulus.

Mitral annular calcification (MAC) is sometimes associated with Carpentier type 2 mitral valve regurgitation and is a challenge to repair. Complete annular decalcification and mitral valve reconstruction is considered the ideal treatment. This report demonstrates the success of chordal replacement and band annuloplasty without resection of the leaflet and MAC. We have followed the patient for 7 years postoperatively, with no progression of MAC and no regurgitation by echocardiography.

[How to repair a mitral valve prolapse;an assessment of operative techniques dependent on late results].

BACKGROUND: In this study, we assessed the repair techniques employed for mitral valve prolapse. PATIENTS AND METHODS: Between 1992 and 2011, we repaired 173 consecutive patients with mitral valve prolapse. The mean age of the patients was 60.1 years and 68.6% were male. For anterior leaflet (AL) prolapse, 27 patients with fibroelastic deficiency (FED) were treated with chordal replacement (CR). In 21 patients with Barlow type, 2 were repaired with CR and the remaining 19 were repaired with resection. In 130 patients with a prolapse of the posterior leaflet (PL), we selected quadrangular resection( QR:44), sliding plasty( SP:12), folding plasty and CR. More recently, triangular resection (TrR:22) was selected for ≤18 mm height leaflets, and an hourglass resection( HgR:21) for high leaflets.Hourglass represents the shape of the resection. RESULTS: In 1 patient of the AL CR group, the expanded polytetrafluoroethylene (ePTFE) was broken. Other patients in this group showed no mitral regurgitation (MR) and no re-operation during 16 years. Two patients receiving CR for AL Barlow received re-repair, whilst the other 19 patients in this group displayed good results over the following 19 years. In the QR and SP groups, 1 patient was rerepaired,whilst 3 patients displayed complicated mitral stenosis. In the TrR and HgR groups, no MR,no re-operation and no late deaths occurred during the following 4.5 years. CONCLUSIONS: CR for AL FED, resection for AL Barlow and TrR or HgR for PL were durable techniques for the treatment of mitral valve prolapse.

[The formula of the aortic valve repair for bicuspid aortic valve].

BACKGROUND: The treatment of aortic regurgitation( AR) with bicuspid aortic valve( BAV) repair is still uncommon as the reproducibility of the repair is low and the 5-year durability is poor. In this study, we examined a method of cusp suspension after triangular resection. In addition, the relationship between the length of the cusp margin and diameter of the sino-tubular( ST) junction was evaluated. PATIENTS AND METHODS: We repaired 8 regurgitant BAVs between 1997 and 2011. The mean patient age was 35±14 years and 87.5% were male. All lesions were raphe type:7 were anterior-posterior type and 1 was left-right type. The basic technique was triangular resection of the pseudo-commissure.When the annulus or ST junction was dilated, annuloplasty or ST junction plication was added. Cusp suspension was performed in 7 patients. In 2 patients, the half-length of the cusp margin (d) was related to the diameter of the ST junction( D) as described by d=D/2+1. RESULTS: Two cases were on a 2nd pump run because of residual AR. The valve was replaced in 1 case, while the cause of AR was found to be symmetric prolapse in the analysis. The coaptation depth was 6.2 mm. Another case was re-repaired because AR was caused by an untied suspension suture.Seven cases( 87.5%) were repaired successfully. No in-hospital deaths or complications occurred. The mean follow-up period was 5.42 years (range 1~15). No patients required re-operation and no recurrent AR greater than moderate occurred. The mean coaptation depth of the 7 successful patients was 11±3 mm. CONCLUSION: When repairing a regurgitant BAV, triangular resection alone is sometimes ineffective due to the occurrence of symmetric prolapse. For reproducible repair, it is useful to add cusp suspension.Lastly, the rate of suspension is related to the diameter of the ST junction.