[A Huge Aortic Root Aneurysm Nineteen Years After Aortic Valve Replacement:Report of a Case].

We report a case of huge aortic root aneurysm 19 years after aortic valve replacement. A 58-year-old woman was referred to us for aortic root dilatation. She underwent aortic valve replacement with mechanical valve due to severe aortic regurgitation of tricuspid aortic valve 19 years ago. We performed graft replacement of aortic root preserving prior mechanical prosthetic valve. Histological examination of aneurysm showed myxomatous change in medial layer. Aortic root dilatation after aortic valve replacement is caused by bicuspid valve, aortic dissection, Marfan syndrome, tissue disorder disease, aortitis, and dilated Valsalva sinus at the time of prior operation. It is important to follow-up a patient for root dilatation after aortic valve replacement.

Impact of skeletal muscle mass on clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

Low skeletal muscle mass is one of the components of sarcopenia. However, the prognostic impact of skeletal muscle mass on clinical outcomes in patients after transcatheter aortic valve replacement (TAVR) remains unclear. Therefore, we assessed the impact of skeletal muscle mass on future cardiovascular events in patients undergoing TAVR. We enrolled 71 consecutive patients who underwent TAVR for symptomatic severe aortic stenosis. We applied bilateral psoas muscles as an indicator of skeletal muscle mass. Psoas muscle volumes were measured from the origin of psoas at the level of the lumbar vertebrae to its insertion in the lesser trochanter on three-dimensional computed tomography datasets. Psoas muscle mass index (PMI) was calculated as psoas muscle volume/height2 (cm3/m2). According to the median value of PMIs (79.8 and 60.0 cm3/m2 for men and women), the enrolled patients were divided into two groups. During the follow-up, 11 (31.4%) patients in low PMI group and 4 (11.1%) in high PMI group experienced major adverse cardiovascular events (MACE) defined as a composite of death from any cause, myocardial infarction, heart failure hospitalization, and stroke. The proportion of MACE-free survival was significantly lower in low PMI group (log-rank P = 0.033), mainly due to the difference of hospital readmission for congestive heart failure. On multivariate Cox proportional hazard analysis, PMI remained an independent negative predictor of MACE [hazard ratio 0.95 (95% confidence interval 0.92-0.98, P = 0.002)]. In conclusion, low skeletal muscle mass independently predicted MACE in patients undergoing TAVR.

[Giant Right Coronary Artery Aneurysm Causing Acute Myocardial Infarction;Report of a Case].

We report a case of giant right coronary artery aneurysm causing acute myocardial infarction. A 59-year-old man presented with syncope and referred to our hospital in ambulance. Electrocardiogram showed acute myocardial infarction of the right coronary artery, and emergent coronary angiography was performed. Angiography confirmed a giant coronary artery aneurysm in the mid-portion of the right coronary artery. He underwent aneurysmectomy and coronary artery bypass grafting to the posterior descending artery. Spontaneous rupture of a giant coronary artery aneurysm is rare, but critical condition such as acute myocardial infarction or fistula to heart chamber can occur. Surgical intervention is indicated for a giant coronary artery aneurysm to prevent possible life-threatening consequences in the future.

Intrapericardial lipoma compressing the right atrium.

We report a case of intrapericardial lipoma compressing the right atrium. Cardiac lipomas are very rare benign tumors that may cause life-threatening complications by rapid growth. A 67-year-old woman presented with dyspnea and palpitations on effort due to compression of the right atrium. The tumor was surgically resected. There was no local recurrence after surgery.

Movement of mitral fibrous components in an isolated porcine working heart model.

BACKGROUND: There is little research regarding the movement of mitral fibrous components. We analyzed changes in mitral fibrous components in normal and deteriorated isolated working swine hearts. METHODS: In 5 swine hearts, 6 sonomicrometry transducers were placed around the mitral annulus and 2 in the papillary muscle tip. During the working cycle, we evaluated the annular dimension and calculated the contraction range and contraction ratio during the cardiac cycle in normal and deteriorated modes. RESULTS: The transverse (24.5 ± 2.3 vs. 27.4 ± 2.4 mm) and posterior longitudinal diameter (18.3 ± 7.0 vs. 22.5 ± 5.5 mm) increased significantly in deteriorated mode. The contraction range in transverse (1.8 ± 0.6 vs. 0.8 ± 0.7 mm) and posterior longitudinal (1.6 ± 0.6 vs. 0.8 ± 0.3 mm) diameters decreased significantly in deteriorated mode. The contraction range of the strut chordae was less than 1.0 mm in both modes, with no significant differences. The contraction ratio of the anterior strut chordae was significantly reduced in deteriorated mode (3.2 ± 1.1% vs. 2.2 ± 1.1%). The contraction ratio of the annulus was significantly lower in deteriorated mode with respect to transverse (6.9 ± 2.1% vs. 2.9 ± 2.9%) and longitudinal (13.3 ± 4.5% vs. 8.6 ± 5.1%) diameters. CONCLUSIONS: In the deteriorated hearts, the mitral annulus was dilated and contractility decreased. The length of the strut chordae differed 1 mm between the deteriorated and normal modes; however, the contraction ratio of the anterior chordae during the cardiac cycle was reduced, indicating increased stretching.

[Right Atrial Rupture due to Blunt Trauma;Report of a Case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We report a case of surgical treatment of blunt cardiac trauma. A 55-year-old man was admitted to our hospital for blunt trauma due to a car accident. His hemodynamics was compromised due to cardiac tamponade. The patient underwent pericardial drainage by small subxiphoid incision. Although about 400 ml of blood was evacuated, hemorrhage was still continuing. After full sternotomy, we found a 3 mm tear in the right atrial appendage and sutured it easily without cardiopulmonary bypass. The patient recovered uneventfully and was discharged on the 10th postoperative day. He is now leading a normal life.

Analysis of myocardial temperature changes in conventional isolated coronary artery bypass grafting.

BACKGROUNDS: To determine whether cold blood cardioplegia (CBCP) can get over coronary artery lesions, we analyzed the relationship between myocardial temperature changes and lesion severity of major coronary arteries. METHODS AND RESULTS: From April 1991 to October 2003, we measured myocardial temperature before and after antegrade and retrograde delivery of CBCP in 492 patients undergoing conventional coronary artery bypass grafting. Stenotic severity of three major coronary arteries was classified into four grades according to preoperative coronary arteriography; grade 0 for 50 % or less, 1 for 75 %, 2 for 90 %, 3 for 99 % or 100 %. We analyzed relationships between myocardial temperature changes [ΔT-A (antegrade) & ΔT-R (retrograde)] and the coronary artery lesion's severity. Average ΔT-A of the right coronary artery had no relationship with stenotic grades. Mean ΔT-A of the left anterior descending (LAD) became less and less in proportion to its stenotic grade [9.7 °C for grade 0, 8.2 °C for grade 1, 7.1 °C for grade 2, and 6.0 °C for grade 3, respectively, (p = 0.0042)]. ΔT-A of the circumflex artery showed similar but weaker tendency than those of LAD. Significant inverse correlations were found between ΔT-A and ΔT-R1 in each territory (p < 0.001). CONCLUSIONS: Antegrade delivery was less effective in situations with tight proximal lesion, especially in the LAD territory. Retrograde delivery supplemented antegrade delivery. Myocardial temperature monitoring enables us to deal with inadequate cardioplegic delivery, and is a good indicator of myocardial protection.

Solitary fibrous tumor causing cardiac tamponade.

Solitary fibrous tumor of the pleura is a rare primary tumor arising from mesenchymal cells in the areolar tissue subjacent to the mesothelial-lined pleura. Most solitary fibrous tumor of the pleura arises from the visceral or the parietal pleura, and asymptomatically occupies the hemithoracic cavity. We report a rare case of solitary fibrous tumor of the pleura causing cardiac tamponade. A 30-year-old woman presented with pericardial tumor. The surgical resection of the tumor was complete. We describe the details of this case and a brief review of the literature about solitary fibrous tumor.

Surgery for coincidental infected distal arch and abdominal aortic aneurysms.

A 63-year old man was admitted to hospital for the treatment of coincidental infected distal arch and abdominal aortic aneurysms. His haemodynamic state was unstable and uncontrollable because of septic shock. Group A beta-haemolytic Streptococcus pyogenes was the responsible microorganism. An emergent extra-anatomical bypass and complete aneurysm excisions were performed without extracorporeal circulation.

[Traumatic aortic injury].

Optimal timing of surgical repair for traumatic aortic injury (TAI) is still controversial. We have experienced 3 cases of TAI. The 1st one suffered from severe multisystem trauma in addition to TAI, so we performed graft replacement of the proximal descending aorta electively 31 days after the injury. The 2nd one had massive pleural effusion on admission and we performed urgent operation. They recovered uneventfully. The last one died of aortic re-rupture during anesthetic induction despite attempting emergent operation. In patients with serious multisystem trauma besides TAI, surgical repair can be delayed as long as there are no signs of on-going rupture and/or bleeding, however close observation, serial computed tomography( CT) check-ups and strict control of blood pressure are needed.

Composite vein graft reconstruction for infected descending aortic prosthesis.

We report a case of successful in situ replacement with a superficial femoropopliteal vein panel graft for Dacron graft infection of the thoracic aorta. A 75-year-old man presented with septicemia and pseudoaneurysm caused by methicillin resistant staphylococcus aureus 2 years after Dacron graft replacement of the mid-descending aortic aneurysm. The patient underwent in situ replacement with a panel graft constructed of 3 deep vein panels after excision of the infected Dacron graft. The patient is free of infection and doing well over 2 years after surgery.

Malignant fibrous histiocytoma originating from right ventricular outflow tract.

A 70-year-old man presented with right heart failure due to obstruction of the right ventricular outflow tract by a large tumor mass. The tumor was surgically resected as much as possible. Neither chemotherapy nor radiotherapy was given. The patient died of local recurrence and multiple lung metastases 6 months after surgery. The prognosis of this very rare primary cardiac tumor is generally poor.

Safety of mild hypothermic circulatory arrest with selective cerebral perfusion.

Although hypothermic circulatory arrest with antegrade selective cerebral perfusion is used for cerebral protection, optimal perfusion characteristics are still unclear. Between May 2006 and March 2008, 26 patients (mean age, 68.9 years; 14 males) underwent thoracic aortic repair with mild hypothermic circulatory arrest (34.3 degrees C +/- 1.9 degrees C) and antegrade selective cerebral perfusion (30 degrees C) for various indications including 16 acute type A aortic dissections. Mean cerebral perfusion rate was 21.1 +/- 4.3mL kg(-1) min(-1). Non-elective operations were carried out in 16 (61.5%) cases. Operative procedures were ascending aortic replacement in 16 patients, hemiarch replacement in 4, and total arch replacement in 6. Cardiopulmonary bypass time was 209 +/- 61 min, cardiac ischemic time was 141 +/- 45 min, cerebral perfusion time was 81 +/- 67 min, and lower body circulatory arrest time was 65 +/- 22 min. Mean rectal temperature drifted to 30.6 degrees C +/- 1.3 degrees C. There was 1 (3.8%) hospital death due to rupture of a residual descending thoracic aneurysm. One patient needed reexploration for bleeding, and 2 (7.7%) suffered permanent neurologic dysfunction. No postoperative spinal cord dysfunction was observed. Mild hypothermic circulatory arrest with antegrade selective cerebral perfusion could be performed safely in our patient population.

Emergency total aortic arch replacement for a renal transplant recipient by mild hypothermia with selective cerebral perfusion.

Hypothermia and immunosuppressive drugs may promote surgical wound infection. We successfully performed an emergency total arch replacement with mild hypothermia and selective cerebral perfusion for a renal transplant recipient. The postoperative course was almost uneventful without any surgical site infection.

Entirely polytetrafluoroethylene coating for pacemaker system contact dermatitis.

A 63-year-old man underwent pacemaker implantation for complete atrio-ventricular block. The patient repeated admissions for skin necrosis, and generator or pacemaker system was re-implanted each time. The patient was admitted with skin necrosis of the generator pocket three years after re-implantation. A skin patch test was positive on almost all components of the pacemaker system. The patient underwent pacemaker system removal and re-implantation of polytetrafluoroethylene (PTFE) sheets coating pericardium leads and generator. There has been no recurrence. PTFE sheet coating is effective to treat pacemaker system contact dermatitis.

Mitral annular reconstruction with anterior leaflet flip-over in concomitant surgery for mitral regurgitation associated with extensive posterior annular calcification and hypertrophic obstructive cardiomyopathy.

We describe a case of severely calcified posterior mitral annulus associated with grade IV mitral regurgitation in addition to significant hypertrophic obstructive cardiomyopathy. A 70-year-old woman underwent successfully annular reconstruction with anterior mitral leaflet flip-over and mitral valve replacement with a bileaflet mechanical prosthesis combined with left ventricular septal myectomy. This technique can serve not only to cover the debrided posterior annulus, but also to eliminate left ventricular outflow tract obstruction and to keep left ventricular function by virtue of not severing ventricular-annular continuity.

Aortic valve replacement after midline-crossed internal thoracic artery grafting.

In the presence of a midline-crossed internal thoracic artery graft, a median sternotomy may jeopardize the graft and compromise hemodynamics. We report successful aortic valve replacement using a "staircase" thoracotomy and hypothermic axillary perfusion with balloon aortic occlusion in 2 men who had patent right internal thoracic artery grafts that was previously anastomosed to the left anterior descending coronary artery.