Fifth-time redo mitral valve replacement via right thoracotomy under systemic hyperkalemia cardiopulmonary bypass without aortic cross-clamp.

The surgical management of prosthetic valvular endocarditis (PVE) can be challenging. We report a case of a 46-year-old female patient who had a history of four cardiac operations. We chose a mitral valve replacement via right thoracotomy to enable optimal exposure of the mitral valve (MV). Because of multi-reoperations, we employed systemic hyperkalemia for cardiac arrest to protect the heart during cardiopulmonary bypass (CPB) without aortic cross-clamping. Here, we present a complex operation that performed management of CPB under hyperkalemia and the patient had a good postoperative recovery.

Alfieri stitch for temporary severe functional mitral regurgitation after aortic valve replacement.

The outcome in functional mitral regurgitation after aortic valve replacement is unclear. A frail 82-year-old woman with severe aortic valve regurgitation and mild to moderate functional mitral valve regurgitation (NYHA functional class III) was referred to our clinic. In consideration of her frail condition, aortic valve replacement without mitral surgery was performed. She had hemodynamic instability and difficulty to wean off cardiopulmonary bypass caused by severe functional mitral valve regurgitation with left ventricular dilatation. A central Alfieri edge-to-edge stitch was placed between the anatomical middle of the two leaflets of the mitral valve after reinstitution of cardiopulmonary bypass. This eliminated the mitral regurgitation, which enabled successful separation from cardiopulmonary bypass.

Gender-linked impact of epicardial adipose tissue volume in patients who underwent coronary artery bypass graft surgery or non-coronary valve surgery.

BACKGROUND: Traditional and non-traditional risk factors for atherosclerotic cardiovascular disease (ASCVD) are different between men and women. Gender-linked impact of epicardial adipose tissue volume (EATV) in patients undergoing coronary artery bypass grafting (CABG) remains unknown. METHODS: Gender-linked impact of EATV, abdominal fat distribution and other traditional ASCVD risk factors were compared in 172 patients (men: 115; women: 57) who underwent CABG or non-coronary valvular surgery (non-CABG). RESULTS: In men, EATV, EATV index (EATV/body surface area) and the markers of adiposity such as body mass index, waist circumference and visceral fat area were higher in the CABG group than in the non-CABG group. Traditional ASCVD risk factors were also prevalent in the CABG group. In women, EATV and EATV index were higher in the CABG group, but other adiposity markers were comparable between CABG and non-CABG groups. Multivariate logistic regression analysis showed that in men, CABG was determined by EATV Index and other ASCVD risk factors including hypertension, dyslipidemia, adiponectin, high sensitive C-reactive protein (hsCRP) and type 2 diabetes mellitus (Corrected R2 = 0.262, p < 0.0001), while in women, type 2 diabetes mellitus is a single strong predictor for CABG, excluding EATV Index (Corrected R2 = 0.266, p = 0.005). CONCLUSIONS: Our study found that multiple risk factors, including epicardial adipose tissue volume and traditional ASCVD factors are determinants for CABG in men, but type 2 diabetes mellitus was the sole determinant in women. Gender-specific disparities in risk factors of CABG prompt us to evaluate new diagnostic and treatment strategies and to seek underlying mechanisms.

Successful management using airway pressure release ventilation for severe postoperative pulmonary edema.

INTRODUCTION: Postoperative pulmonary edema is a fatal adverse event after a cardiac surgery. We here report successful management using airway pressure release ventilation (APRV) for severe hypoxia with pulmonary edema after a cardiac surgery. PRESENTATION OF CASE: A 58-year-old man underwent an uneventful mitral valve repair. Immediately afterwards, the patient became agitated and made vigorous inspiratory efforts. His oxygen saturation dropped to 90%. Coarse inspiratory rhonchi were heard on auscultation, and copious, pink, frothy sputum was obtained with suctioning. Initial chest radiograph showed right-sided patchy opacities and interstitial infiltrates. A transthoracic echocardiogram demonstrated normal cardiac function. With worsening respiratory failure on mechanical ventilation, APRV was attempted. His condition and blood gas was subsequently improved. Over the following 3days, the patient experienced an uneventful postoperative course and was discharged to home on postoperative day 14. DISCUSSION: Extracorponeal membrane oxygenation (ECMO) is the most effective for severe hypoxia with pulmonary edema; however, ECMO is associated with hemorrhage and infectious complications. Alteratively, APRV was required for the successful management for severe hypoxia with pulmonary edema. CONCLUSION: APRV could be effective for severe hypoxia with pulmonary edema after a cardiac surgery.

A new hybrid sutureless patch repair utilizing chitosan for left ventricle rupture after myocardial infarction: A case report.

INTRODUCTION: There are many publications reporting the use of TachoSil sheets for sutureless repair. Trauma doctors have recently reported that chitosan-based sheets can efficiently achieve hemostasis for active bleeding. PRESENTATION OF CASE: An 85-year-old man was diagnosed with left ventricle free wall rupture that caused cardiac tamponade and cardiogenic shock. Extracorporeal membrane oxygenator (ECMO) was started immediately and surgical repair was planned. Bleeding occurred from a 1-cm tear in the center of the necrotic area in the territory of the left circumflex artery. The tear was treated with a chitosan-based HemCon Bandage. After hemostasis of the myocardium was achieved, the bandage was peeled off and a patch repair was performed using collagen fleece with fibrinogen-based impregnation. His condition subsequently improved. The tracheal tube was extubated and ECMO was removed 2days after the surgery. One month later, the patient had no complications at his postoperative follow-up visit. DISCUSSION: To our knowledge, this is the first report of a hybrid patch repair utilizing chitosan-based sheets for a left ventricle rupture after myocardial infarction. Further studies are necessary to evaluate the short- and long-term efficacy of this procedure, and these results must be compared with those of classical surgical repairs. CONCLUSION: The new hybrid sutureless patch utilizing chitosan was demonstrated as safe, easy and effective.

Blunt Abdominal Aortic Injury Associated with L2 Vertebral Fracture.

Blunt abdominal aortic injury (BAAI) is very rare. In general, BAAI occurs in high-energy accidents. Here, we present a case of BAAI in a low-energy accident. A 70-year-old female was injured after falling 3 m. Her vital signs were stable. She had lumbar fractures (L1, L2) and BAAI associated with a fragment of the fractured L2 vertebral body. On the fifth posttrauma day, we performed an operation because computed tomography showed a bone fragment of the lumbar fractures (L1, L2) threatening the abdominal aorta. The aortic injury site was transected, and the fragment of the L2 vertebral body was removed. Even in low-energy accidents, BAAI should be considered. BAAI with stable vital signs can be electively treated.

Successful management of threatened aortic rupture late after rib fracture caused by blunt chest trauma.

A 62-year-old man was crushed in a car accident and diagnosed with a fractured left ninth rib, pulmonary and heart contusion, hemopneumothorax, and descending aortic injury based on a computed tomography scan. He underwent chest tube drainage and was intubated for mechanical ventilation because a bone fragment of the ninth rib threatened to penetrate the descending aorta. On the second posttrauma day, computed tomography showed the bone fragment of the ninth rib approaching the descending aorta. He underwent graft replacement of the injured portion of the descending thoracic aorta, and we removed the fractured left ninth rib.

Effects of myocardial infarction on the distribution and transport of nutrients and oxygen in porcine myocardium.

One of the primary limitations of cell therapy for myocardial infarction is the low survival of transplanted cells, with a loss of up to 80% of cells within 3 days of delivery. The aims of this study were to investigate the distribution of nutrients and oxygen in infarcted myocardium and to quantify how macromolecular transport properties might affect cell survival. Transmural myocardial infarction was created by controlled cryoablation in pigs. At 30 days post-infarction, oxygen and metabolite levels were measured in the peripheral skeletal muscle, normal myocardium, the infarct border zone, and the infarct interior. The diffusion coefficients of fluorescein or FITC-labeled dextran (0.3-70 kD) were measured in these tissues using fluorescence recovery after photobleaching. The vascular density was measured via endogenous alkaline phosphatase staining. To examine the influence of these infarct conditions on cells therapeutically used in vivo, skeletal myoblast survival and differentiation were studied in vitro under the oxygen and glucose concentrations measured in the infarct tissue. Glucose and oxygen concentrations, along with vascular density were significantly reduced in infarct when compared to the uninjured myocardium and infarct border zone, although the degree of decrease differed. The diffusivity of molecules smaller than 40 kD was significantly higher in infarct center and border zone as compared to uninjured heart. Skeletal myoblast differentiation and survival were decreased stepwise from control to hypoxia, starvation, and ischemia conditions. Although oxygen, glucose, and vascular density were significantly reduced in infarcted myocardium, the rate of macromolecular diffusion was significantly increased, suggesting that diffusive transport may not be inhibited in infarct tissue, and thus the supply of nutrients to transplanted cells may be possible. in vitro studies mimicking infarct conditions suggest that increasing nutrients available to transplanted cells may significantly increase their ability to survive in infarct.

Surgical management of a ruptured pseudoaneurysm late after total arch replacement with omentoplasty.

Aortic pseudoaneurysm is a rare, life-threatening complication after cardiac or aortic surgery. In this article, we report reoperation on an 86-year-old man undergoing total arch replacement and omentoplasty for an infectious aortic aneurysm, 5 years previously. He was transferred to our hospital and fell into shock. Prompt drainage of the right-side pleural cavity manifested 2000 ml of blood. Computed tomography revealed contrast extravasation into a pseudoaneurysm, which arose from the proximal anastomotic site of the ascending aorta. The patient underwent emergent surgery that included an extremely careful dissection of the omentum and pericardial adherences, through the re-sternotomy. The patient recovered without neurological sequelae.

Long-term extracorporeal membrane oxygenator support in resuscitation for intractable hibernating myocardium after coronary artery bypass grafting.

We report our experience of long-term extracorporeal membrane oxygenator (ECMO) support to resuscitate a 62-year-old man who had critical three-vessel disease of coronary artery complicating intractable hibernating myocardium (HM) and sudden cardiogenic shock. Intra-aortic balloon pump and ECMO were deployed to restore the circulatory support while emergent revascularization surgery was performed.The patient was weaned from ECMO successfully after 15 days of support and discharged with recovered left ventricular function. ECMO is effective in resuscitation of patients with cardiogenic shock and HM. To our knowledge the present case necessitated the longest term of ECMO support to get rid of HM.

Palliative surgery for malignant mediastinal tumor invading the superior vena cava and right atrium.

Intra-atrial extension of a superior vena cava (SVC) tumor is rare and it is associated with high mortality rates. An 80-year-old woman presented with malignant mediastinal tumor invading the superior vena cava and right atrium. The unresectable tumor caused uncontrolled SVC syndrome and led to the risk of pulmonary artery tumor thrombosis. Palliative surgery for the intracaval and atrial tumor was performed. Presently, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor.

Patch annulo-aortoplasty in an adult patient with congenital supravalvular aortic stenosis and a small aortic annulus.

A 39-year-old woman with familial homozygous hypercholesterolemia had supravalvular and valvular aortic stenosis. Modified Nick's procedure and aortic valve replacement was performed to relieve both the supravalvular and annular stenoses. At surgery, the ascending aorta was found to be narrowing at the level of the sinotubular junction, which was compatible with congenital supravalvular aortic stenosis. Histological examination of the aortic cusps showed sclerotic change due to hypercholesterolemia. These findings indicated that familial homozygous hypercholesterolemia caused valvular aortic stenosis and exacerbated congenital supravalvular aortic stenosis.