Enhanced expression of neopterin in valve tissue of bicuspid aortic stenosis.

Background: Aortic valve stenosis (AS) occurs in bicuspid aortic valve (BAV) patients at a relatively young age compared to tricuspid aortic valve (TAV) patients. However, the underlying cause of this phenomenon remains unknown. Neopterin, which is a by-product of the guanosine triphosphate (GTP) pathway, enhances the oxidative potential of reactive oxygen species. To clarify the role of neopterin in the aortic valve, we immunohistochemically studied the presence of neopterin in aortic valve specimens from patients with AS harboring either TAV or BAV. Methods: Frozen aortic valve samples were surgically obtained from 68 patients with severe AS with TAV (n=34) and BAV (n=34). Normal aortic valves were obtained from cadavers who died of non-cardiovascular causes as controls (n=9). Samples were immunohistochemically stained with antibodies against smooth muscle cells, macrophages, T lymphocytes, neopterin, and 4-hydroxy-2-nonenal (4-HNE). Results: Quantitative analysis showed that the percentage of macrophages, 4-HNE- and neopterin-positive macrophage score, and the number of T lymphocytes were significantly higher in BAV patients than in TAV patients (macrophages, P=0.013; T lymphocytes, P=0.011; neopterin, P<0.001; 4-HNE, P=0.008). Double immunostaining for neopterin and macrophages demonstrated that most neopterin-positive cells were macrophages in BAV patients. Conclusions: Neopterin accumulation in macrophages may increase oxidative stress and contribute to the early onset of AS in BAV.

Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair.

BACKGROUND: Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it's not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually. CASE PRESENTATION: We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms. CONCLUSION: In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.

Delayed traumatic aortic valve perforation after blunt chest trauma.

BACKGROUND: Aortic valve perforation is a rare complication of blunt chest trauma. We report a case of delayed aortic insufficiency presenting several months after trauma. CASE PRESENTATION: A 17-year-old male presented to the emergency department with traumatic brain injuries and blunt chest trauma, but no evidence of cardiac injuries. Three months later, he developed acute heart failure due to severe aortic valve regurgitation with left ventricular dysfunction. A sizable tear in the right coronary cusp caused aortic insufficiency. He was treated successfully by surgical replacement with an aortic bioprosthesis. CONCLUSION: We reported a successful surgical case of valve replacement for delayed aortic valve perforation. Delayed valve perforation should be kept in mind after blunt chest trauma.

Aortic Annular Enlargement with Modified Y-Incision Technique Devised from Preoperative Three-Dimensional Computed Tomography.

The Y-incision technique introduced by Dr. Bo Yang in 2021 is a very innovative technique that can enlarge the aortic annulus by two or more sizes without violating the left atrium or mitral valve. However, we encountered a case in which the left coronary artery ostium was located close to the left-non commissure. Therefore, we considered it would be dangerous to expand the incision to the left coronary annulus. We therefore devised a new technique that enlarges only the noncoronary annulus in an "L" fashion instead of a "Y" fashion. In performing this surgery, preoperative three-dimensional images were useful for understanding the anatomy when planning the aortic annular enlargement procedure. The L-incision technique can be a useful alternative method of aortic annulus enlargement.

Flexible Total Ring Annuloplasty With Continuous Wrapping Suture Considering the Anatomy and Histology of the Tricuspid Valve.

OBJECTIVE: About half of tricuspid valves (TVs) have 2 posterior leaflets, and the fibrous tissue of the tricuspid annulus is poor. Considering the anatomy and histology of the TV, we devised a secure ring annuloplasty technique. We herein report the outcomes of our continuous wrapping suture annuloplasty technique using a flexible total ring. METHODS: We used a Tailor™ ring (Abbott, Chicago, IL, USA) as a full ring. The mark on the left side of the ring was fixed to the anteroseptal commissure, and the midpoint of the ring's markers was fixed at the center of the septal leaflet annulus. Using a continuous suture, all stitches were passed around the annuloplasty ring without penetration. One suture from the anteroseptal commissure ran toward the left side and another from the midpoint of the septal leaflet annulus ran toward the right, leading to annuloplasty without TV deformation. RESULTS: Eighty patients underwent TV repair with this technique. The tricuspid regurgitation (TR) score in all patients improved from 1.9 ± 0.7 to 0.8 ± 0.4 (P < 0.001) at 3 years postoperatively. The TR score of TVs with 2 posterior leaflets also improved from 1.9 ± 0.7 to 0.6 ± 0.4 after the operation and was unchanged during follow-up. The median follow-up period was 1.3 (0.5 to 2.0) years, and no patients required TV reoperation. The 3-year survival rate was 93%, and the 3-year rate of freedom from pacemaker implantation was 95%. CONCLUSIONS: The continuous wrapping suture technique using a flexible total ring is a useful procedure without TV deformation even when 2 posterior leaflets are present.

[Congenital Unicuspid Aortic Valve Diagnosed by Intraoperative Findings].

A unicuspid aortic valve is an extremely rare congenital aortic valvular abnormality. We herein present 2 cases of unicuspid aortic valve diagnosed based on intraoperative findings. In case 1, a 75-year-old man was admitted to our hospital because of severe aortic regurgitation. We performed aortic valve replacement using a bioprosthetic valve, and a unicuspid aortic valve was definitively diagnosed according to the intraoperative findings. In case 2, a 54-year-old man developed dyspnea due to severe aortic stenosis. Aortic valve replacement using mechanical valve was performed, and we were able to diagnose unicuspid aortic valve intraoperatively. Achieving a preoperative definitive diagnosis of congenital unicuspid aortic valve by transthoracic echocardiography is reportedly difficult;however, transesophageal echocardiography may be effective for preoperative definitive diagnosis.

Aortic root remodeling in a patient with Turner syndrome using the reference curves of aortic diameters in children.

We report the successful surgical treatment of aortic regurgitation in a 27-year-old woman with Turner syndrome (TS) who was admitted with exacerbation of dyspnea on exertion. Echocardiography showed a bicuspid aortic valve with severe aortic regurgitation and computed tomography showed dilatation of the ascending aorta and aortic root. Due to the patient's low body surface area (due to TS), standard determination of aortic size was not possible; therefore, we used the reference curves of aortic diameters in children. Because of the possibility of fatal ascending aortic dissection and rupture, we performed concomitant aortic root remodeling and aortic valve repair.