A Surgical Case of Partially Unroofed Coronary Sinus Atrial Septal Defect in an Elderly Patient Diagnosed by Preoperative Contrast-Enhanced Computed Tomography.

Unroofed coronary sinus syndrome is a rare congenital cardiac anomaly, involving some anatomical variations. Approximately 60% of patients with unroofed coronary sinus syndrome have a concomitant atrial septal defect, which is termed unroofed coronary sinus atrial septal defect (CSASD). The precise detection of these abnormalities has been usually difficult with conventional echocardiography, mostly due to its small and complex structures. Herein, we report a case with unroofed coronary sinus atrial septal defect, in which preoperative contrast-enhanced computed tomography (CT) was useful in the operative decision making. We successfully repaired the defective roof of the coronary sinus with a bovine patch, while eliminating the inter-atrial shunt. The patient's postoperative course was uneventful with no residual shunt.

Localized dissection of the sinus of Valsalva mimicking spontaneous coronary artery dissection.

A 56-year-old man, suspected of having ST-segment elevation myocardial infarction due to spontaneous coronary artery dissection, underwent emergency percutaneous coronary intervention. Although he had moderate aortic regurgitation with aortic root dilation and mild heart failure, it was controlled with medications. Two weeks after discharge, he was readmitted with severe heart failure due to severe aortic regurgitation and underwent an aortic root replacement. Intraoperative findings revealed that localized dissection of the sinus of Valsalva involved the right coronary artery, resulting in coronary artery dissection. In cases of spontaneous coronary artery dissection, attention should be paid to coronary artery dissection caused by localized aortic root dissection.

Contemporary Management of Stable Coronary Artery Disease　- Implications of the ISCHEMIA Trial.

Coronary artery disease (CAD) remains a leading cause of mortality and morbidity in developed countries. Although urgent revascularization is the cornerstone of management of acute coronary syndrome (ACS), for patients with stable CAD recent large-scale clinical trials indicate that a mechanical 'fix' of a narrowed artery is not obviously beneficial; ACS and stable CAD are increasingly recognized as different clinical entities. We review the perspectives on (1) modifying the diagnostic pathway of stable CAD with the incorporation of modern estimates of pretest probability, (2) non-imaging evaluations based on their availability, (3) the optimal timing of invasive coronary angiography and revascularization, and (4) the implementation of medical therapy during the work-up.

Optimal phase analysis of electrocardiogram-gated computed tomography angiography in patients with Stanford type A acute aortic dissection.

OBJECTIVE: To determine the phase that facilitates flap observation of the ascending aorta in Stanford type A acute aortic dissection with perfused false lumen. METHODS: We reconstructed retrospective Electrocardiogram-gated Computed Tomography Angiography images of the ascending aorta of all 20 patients to 20 phases of curved-multiplanar reconstruction in 5% increment. One radiologist created and randomized 10 cross-sectional images of each phase for every patient and two radiologists scored these images on a 5-point scale depending on the degree of flap stoppage. We calculated the average score for each phase of each case and compared them among the three groups. RESULTS: Image scores were significantly better in the 65 %-100 % R-R interval group than those in the 5%-30 % (p < 2e-16) and 35 %-60 % R-R interval groups(p = 7.2e-10). Similar scores were observed in the Heart Rate > 70 group (p = 0.00039, 2.2e-14). Moreover a similar tendency was observed in the arrhythmia group (p = 0.0035, 0.294). No difference was found in the degree of flap stoppage in the 65 %-100 % R-R interval group between the Heart Rate > 70 and Heart Rate ≤ 70 groups (p = 0.466) and between the arrhythmia and non-arrhythmia groups (p = 0.1240). CONCLUSION: In observing the ascending aorta, We obtained a good image at 65 %-100 % R-R interval and similar tendency was observed in the patients with arrhythmia.

Hemodynamic performance and incidence of patient-prosthesis mismatch of small-sized Trifecta pericardial aortic valves.

OBJECTIVES: Small-sized bioprosthetic valves are sometimes associated with suboptimal hemodynamic performance, leading to a patient-prosthesis mismatch. Trifecta pericardial valves are designed to improve hemodynamic performance. The purpose of this study was to investigate the hemodynamic properties of small-sized Trifecta valves and their efficacy in preventing a patient-prosthesis mismatch. METHODS: This was a retrospective analysis of 108 patients undergoing surgical aortic valve replacement with a Trifecta valve of 23 mm or less in a single Japanese institution. The hemodynamic performance was evaluated with an echocardiography examination in all patients after surgery, and the development of a patient-prosthesis mismatch was judged with the measured in vivo indexed effective orifice area. RESULTS: There was one early and seven late mortalities. There were no valve explants due to structural valve deterioration. Postoperative mean pressure gradients of 19-, 21-, and 23-mm valves were 15.1, 11.4, and 9.0 mmHg, respectively. The effective orifice area of 19-, 21-, and 23-mm valves was 1.41, 1.69, and 1.78 cm2, respectively. Patient-prosthesis mismatch occurred in 14 patients (1 severe and 13 moderate) and the incidence was 13.0% (15.4% in 19 mm, 18.0% in 21 mm, and 3.3% in 23 mm). CONCLUSIONS: The small-sized Trifecta valves showed excellent hemodynamic performance and were associated with a low incidence rate of patient-prosthesis mismatch.

Safety and efficacy of a simple cardiotomy suction system as a blood salvage procedure during off-pump coronary artery bypass surgery.

The ideal blood-salvaging strategies for off-pump coronary artery bypass graft procedures have not been determined. We developed a new blood-salvaging system that uses a cardiotomy suction. The purpose of this study was to examine the efficacy of this novel method. This was a retrospective study involving 50 consecutive patients undergoing off-pump coronary artery bypass grafting. In 25 patients, a simple cardiotomy suction system was used (cardiotomy suction group). These individuals were compared with 25 historical cohorts who were treating with the conventional cell saver system (cell saver group). There was no in-hospital mortality in either group. In the cell saver group, there was one major complication (stroke) and two minor complications (saphenous vein graft occlusion, superficial wound infection). In the cardiotomy suction group, there was one minor complication (subclinical pulmonary emboli). The cardiotomy suction group received significantly fewer transfused RBC (cardiotomy: 0.56 ± 1.4 units vs. cell saver: 2.46 ± 3.3 units, p = 0.005). The serum total protein and albumin levels were significantly higher in the cardiotomy group. Our newly developed simple cardiotomy suction system, when compared with the conventional cell saver system, produced similar clinical results and attenuated postoperative hemodilution. Our system may emerge as a preferable alternative for blood salvage during off-pump coronary artery bypass grafting.

Unexpected intraoperative coronary malperfusion after primary repair of acute type A aortic dissection with surgical glue.

In the surgical treatment of acute aortic dissection, the attachment of the dissected wall using surgical glue can be an effective procedure to stabilize the fragile dissected wall. A 42-year-old man underwent aortic root replacement for acute type A aortic dissection. However, after aortic declamping, he experienced severe myocardial impairment, which required an additional procedure of coronary artery bypass grafting. The unexpected myocardial ischaemia can be attributed to the inattentional use of surgical glue.

Management of systolic anterior motion of the mitral valve: a mechanism-based approach.

Although the mechanism of systolic anterior motion (SAM) of the mitral valve is unknown, it is known to have a multifactorial pathophysiology. Echocardiographic analysis of the mitral leaflet revealed the step-wise progression of SAM, and intraventricular flow analysis revealed the contribution of drag force generated by the misled flow below the posterior leaflet. Although several diverse clinical features of SAM are already known, some key features need to be abstracted from among them to understand the regulation of SAM establishment. This paper reviews past articles that have investigated the mechanism of SAM and proposes a mechanism-based concept to provide insights for better comprehension of SAM recognition.

Radiation therapy for recurrent cardiac undifferentiated pleomorphic sarcoma after three operations.

We report the case of a 57-year-old female suffering from recurrent malignant undifferentiated pleomorphic sarcoma of the left atrium. Metastasis to the posterior mediastinum was detected upon first presentation. Incomplete resections were carried out twice before mitral valve replacement was finally performed. The tumor recurred 16 months later and was treated with radiation therapy, which has proved to be effective in bringing about tumor regression for 2 years, to date. The patient has survived for 7 years since the first surgery.

Proposal of a novel index for selection of optimal annuloplasty ring size for tricuspid annuloplication.

BACKGROUND: Optimal ring size in tricuspid annuloplasty (TAP) surgery to treat functional tricuspid regurgitation (TR) was investigated because optimal ring size remains undefined. METHODS AND RESULTS: Sixty seven patients who underwent TAP at our institution were retrospectively studied. Tricuspid Annuloplasty Ring size Index (TARI) was defined as implanted tricuspid annuloplasty ring size divided by body surface area (BSA). Different TARI cut-off values were tested to determine which value produced the greatest difference in TR improvement (TRI=preoperative minus postoperative TR grade) between patients with TARI smaller (group S) and larger (group L) than the cut-off. Group S was also subdivided by ring type: Cosgrove rings (SC) and MC3 rings (SM). TARI and TRI were negatively correlated (r=-0.307). A TARI threshold of 18.9 mm/m(2) produced the greatest and most significant difference (P<0.0005) in TRI. Defining groups S and L using this threshold, TRI was significantly greater for group S (1.77 ± 0.80) than for group L (0.97 ± 0.83); P <0.0005. There was no difference in TRI between groups SC and SM. CONCLUSIONS: A novel index TARI that normalizes tricuspid annuloplasty ring size by BSA was developed. Choosing ring size to make TARI <18.9 mm/m(2) is likely to be better than setting an upper limit of absolute ring size in the surgical treatment of TR.

Do semi-rigid prosthetic rings affect left ventricular function after mitral valve repair?

BACKGROUND: After reports of cardiac impairment caused by mitral annuloplasty with rigid rings, several prosthetic rings with semi-rigidity were introduced. The influence of semi-rigid rings on postoperative cardiac function remains unknown. This study compared postoperative cardiac function between patients receiving a semi-rigid prosthetic ring and those receiving a flexible ring or band. METHODS AND RESULTS: Transthoracic echocardiographic data of 305 patients who underwent mitral valve repair for degenerative mitral regurgitation (227 patients receiving a semi-rigid ring and 78 receiving a flexible ring or band) were retrospectively reviewed. The imbalance in the preoperative characteristics between groups was adjusted with propensity score matching. Left ventricular ejection fraction, end-diastolic dimension, and end-systolic dimension were compared at 1 week, 6 months, and 1 year after surgery. Propensity score matching yielded 68 matched pairs of patients for whom there were few group differences in preoperative covariates. Between patients receiving a semi-rigid ring and those receiving a flexible ring or band in the propensity-matched cohorts, there were no significant differences in ejection fraction (P=0.322), end-diastolic dimension (P=0.576), or end-systolic dimension (P=0.567). CONCLUSIONS: There was little difference in the influence on postoperative cardiac function between semi-rigid rings and flexible rings or bands.

Influence of left ventricular function on development of systolic anterior motion after mitral valve repair.

OBJECTIVE: A hyperkinetic heart has been suggested as a risk factor for systolic anterior motion (SAM) after mitral valve repair, but the influence of preoperative left ventricular (LV) function on the development of SAM has not been elucidated. METHODS: Transthoracic echocardiographic data were retrospectively reviewed in 441 patients who underwent mitral valve repair for degenerative mitral regurgitation. Comparisons were made between patients with and without SAM (SAM cases vs noncases). RESULTS: The incidence of SAM was 6.1% (27/441). There were no differences in preoperative characteristics and operative procedures between the 2 groups except the prevalence of Barlow disease. The SAM cases exhibited a higher preoperative ejection fraction (EF) (SAM cases, 70.0% ± 7.1%; noncases, 65.1% ± 6.9%; P < .01) and smaller preoperative systolic LV end-systolic dimension (LVDs) (32.0 ± 5.4 mm vs 35.4 ± 5.7 mm; P = .02) than the noncases. The incidence of SAM was significantly associated with greater preoperative EF (P < .01 for trend) and reduced LVDs (P < .01 for trend). SAM did not occur in patients with an impaired (EF < 60%) or enlarged (LVDs > 45 mm) LV. The incidence of SAM was highest among patients with a small hyperkinetic heart. CONCLUSIONS: The study indicates that the development of SAM after mitral valve repair is associated with preoperative LV function. A small hyperkinetic heart is considered a risk factor for SAM and should be treated with caution.

Impact of papillary muscle approximation on mitral valve configuration in the surgical correction of ischemic mitral regurgitation.

BACKGROUND: Efficacy of papillary muscle approximation (PMA) has not been well defined. METHODS: Mitral valve configuration was assessed using echocardiography before and 1 week after the surgery in 27 consecutive patients undergoing surgical correction of ischemic MR. Comparisons were made between patients undergoing restrictive mitral annuloplasty (RMAP) alone (n = 13, RMAP group) and those undergoing PMA in addition to RMAP (n = 14, PMA group). RESULTS: In the RMAP group, the annular diameter was reduced by 43% after surgery, and annular reduction was greater in the posterior portion than in the anterior. Consequently, the tethering angle of the posterior leaflet (PL) increased after surgery. In the PMA group, the annular diameter was reduced by 33%, and annular reduction was greater in the posterior. In this group also, the tethering angle of PL increased significantly after surgery, although the degree of augmentation was lower compared with that in the RMAP group. CONCLUSION: The addition of PMA to RMAP could attenuate but do not eliminate the tethering augmentation of PL.

Morphological analysis of systolic anterior motion after mitral valve repair.

OBJECTIVES: The systolic anterior motion (SAM) of mitral valves occurs at a certain rate despite the introduction of several preventive procedures. The purpose of this study was to investigate its mechanism by analysing the change in mitral valve morphology associated with operative procedures. METHODS: Components of mitral valves were measured before and after operative procedures by transoesophageal echocardiography in 179 patients who underwent mitral valve repair. Comparisons were made between 15 patients with SAM (SAM group) and 164 patients without SAM (non-SAM group). RESULTS: Morphological analysis in all the studied patients revealed that operative procedures shifted the coaptation point towards the left ventricular outflow tract by 6.9 mm and increased the extra portion of anterior leaflet that extended beyond the coaptation point by 5.4 mm. These changes were enhanced in the SAM group. Intergroup comparison revealed that there were no differences in the preoperative mitral valve morphologies between the two groups. After operative procedures, however, the SAM group showed smaller annular diameter and smaller coapted anterior/posterior length ratio compared with the non-SAM group. CONCLUSIONS: The results of this study show that operative procedures might modify the morphology of mitral valves susceptible to developing SAM. Postoperative smaller annular diameter and anterior shift of coaptation point were considered to contribute to the development of SAM.