[Modified infarction exclusion technique for surgical treatment of postinfarction ventricular septal rupture].

A ventricular septal rupture (VSR) is a fatal complication after an acute myocardial infarction. Surgical repair with an infarction exclusion technique (IET) has improved the surgical outcome for VSR. However, a residual shunt from the left ventricle to the right ventricle has been still one of the problems associated with this technique. We modified the IET so as to avoid the occurrence of the residual shunt In our modification, interrupted mattress sutures were placed transmurally to obtain a secure fixation of the pericardial patch. As for the interventricular septum, the VSR was enlarged to about 1.5 cm in diameter with a cavitron ultrasonic surgical aspirator to facilitate the placement of transmural sutures from the right ventricle to the left ventricle. We performed VSR repair with this modified IET in 3 patients, and have obtained beneficial results.

[Left ventricular pseudo-false aneurysm after a myocardial infarction; application of heart positioner].

We herein present the case of a pseudo-false aneurysm which developed in a patient after a myocardial infarction in the posterior left ventricular wall. A 71-year-old man experienced an acute myocardial infarction due to occlusion in the left circumflex artery. Five weeks after the myocardial infarction, echocardiography and magnetic resonance imaging (MRI) disclosed a pseudo-false aneurysm at the posterior left ventricular wall. A patch closure of the aneurysm and coronary artery bypass grafting (CABG) to both the left anterior descending artery and the left circumflex arteries were successfully performed. At surgery, the Starfish Heart Positioner, a commercially available device that is designed to lift the heart during off-pump CABG, was found to be very useful for exposing the posterior left ventricular wall by lifting and fixing the apex of the left ventricle.

[Valvuloplasty for aortic regurgitation with bicuspid valve: report of a case].

A 32-year-old male patient with bicuspid aortic valve underwent valvuloplasty for the treatment of aortic regurgitation. The aortic regurgitation was estimated to be grade III based on the transthoracic echocardiography and aortography findings. Transesophageal echocardiography showed prolapse of the conjoined leaflet. At surgery, the valvuloplasty consisted of triangular resection and re-suture of the prolapsed larger leaflet, and subcommissural annuloplasty. The degree of the aortic regurgitation decreased to very slight degree after the repair. The peak pressure gradient across the repaired aortic valve was 8.8 mmHg. The patient was discharged without any complications. The bicuspid aortic valve demonstrating aortic regurgitation seems to be repairable. As a result, the valvuloplasty is indicated for such patients, especially for young patients.

A very rare anatomic variation of the right ventricular branch: right ventricular descending branch from the anterior interventricular branch.

The anterior interventricular branch of the left coronary artery has the most constant distribution in the human heart and rarely gives off right ventricular branches. Here we report a case with a right ventricular branch which diverged from the anterior interventricular branch and descended on the anterior right ventricular wall parallel to the anterior interventricular sulcus; we termed it the "right ventricular descending branch." This artery gave a collateral artery to the occluded anterior interventricular branch at the apex, and had prevented anterior myocardial infarction. The right ventricular descending branch should be precisely identified in order to perform successful myocardial revascularization procedures such as coronary artery bypass grafting and percutaneous coronary intervention, especially in a patient with anterior interventricular branch occlusion.

[Skeletonized right gastroepiploic artery for coronary artery bypass grafting; evaluation of intraoperative graft flow and postoperative angiographic result].

We evaluated the efficacy of using the skeletonized right gastroepiploic artery (RGEA) in coronary artery bypass grafting (CABG). The RGEA was harvested either as a pedicle (group P, n = 14) or in a skeletonized fashion using a Harmonic Scalpel (group S, n = 14). The free flow of the RGEA was too small to be measured in some cases in group P. On the other hand, the free flow of the RGEA could be measured in all cases in group S, and that value obtained was comparable to the free flow of the left internal thoracic artery. The skeletonization of the RGEA also allowed us to directly visualize this vessel, and thus helped us to evaluate the quality of this artery. Postoperatively, all RGEAs were patent in both groups. The RGEA diameters on the postoperative angiography showed the RGEAs in group S to have a wider caliber, however, the differences in the values for each group did not reach statistic significance. Neither the operation time nor the postoperative hospital stay were substantially lengthened due to the skeletonization of the RGEA. In conclusion, the skeletonization of the RGEA using a Harmonic Scalpel is safe and effective modality which enables surgeons to directly visualize arteries in order to determine their quality and thereby making it easier to perform sequential bypass grafting. The method also demonstrated an excellent quality of the patent graft on postoperative angiography. We therefore consider the skeletonization of the RGEA to be a very useful method for harvesting the RGEA in CABG.

[Aortic valve regurgitation associated with rheumatoid arthritis; report of a case].

We report a rare case of aortic regurgitation (AR) associated with rheumatic arthritis (RA). A 59-year-old female was brought to our hospital with cardiopulmonary arrest because of severe heart failure due to AR. After being treated for heart failure, aortic valve replacement was carried out with a Carpentier-Edwards 21 mm model. During operation, it was observed that all of the coronary cusps had become thickened and shortened. A part of the right coronary cusp near the commissure of the left coronary cusp was especially badly affected. Valve histology showed a typical degeneration pattern. The patient had an uneventful postoperative course. It appears likely that the aortic valve had become shortened during the recovery process from inflammation caused by RA. The use of bioprostheses is beneficial in RA patients with aortitis, gastric ulcers, etc., since they reduce dynamic stress and eliminate the need for use of anti-coagulants.

[Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery].

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.

[Emergency coronary artery bypass grafting for acute coronary syndrome with preoperative intraaortic balloon pumping; comparative surgical outcome and long-term results].

With recent technical improvements in catheter interventional therapy, percutaneous coronary intervention (PCI) has now become the treatment of first choice for acute coronary syndrome (ACS). The objective of the present study was to evaluate critically the timing of coronary artery bypass grafting (CABG) for severe ACS with preoperative intraaortic balloon pumping (IABP). Since 1994, a total of 70 patients have gone emergency or urgent CABG for ACS. Of 70 patients, 50 patients required preoperative IABP. There were 22 patients (17 men, 5 women) with acute myocardial infarction (AMI), with a mean age of 67.7 years, and 28 patients (19 men, 9 women) with unstable angina pectoris (UAP), with a mean age of 69.2 years. There was a significant difference, between AMI and UAP, in the prevalence of emergency operation (95.5% vs 25.0%), in preoperative cardiogenic shock (81.8% vs 17.9%), in the level of preoperative CPK-MB (196.7 IU/l vs 2.0 IU/l) and in preoperative ejection fraction (41.8% vs 47.3%). Two patients in AMI required percutaneous cardiopulmonary support (PCPS). Thirteen patients in AMI and 22 patients in UAP presented left main trunk (LMT) disease. Of the 13 LMT patients in AMI, 4 patients were AMI due to acute occlusion in the LMT. The AMI patients received 2.45 distal anastomoses on average, while the UAP patients 3.14 distal anastomoses (p = 0.019). Excluding the mean number of distal anastomoses, there was no difference in the intraoperative technical factors, such as aortic cross clamping duration, cardiopulmonary bypass duration, rate of complete revascularization, between AMI and UAP. There were postoperative significant differences in low cardiac output syndrome (LOS) [45.6% in AMI vs 3.6% in UAP] and in prolongation of mechanical ventilation (59.1% in AMI vs 14.3% in UAP). The hospital mortality was 9.1% (2/22) in AMI, and 3.6% (1/28) in UAP, with no significant difference. Of these 3 patients, 1 patient died from perioperative cerebrovascular accident (CVA), another from LOS, and the other from postoperative mesenteric ischemia, with an overall mortality of 6.0% (3/50). The overall patency rate of the grafts was 100% in AMI and 96.6% in UAP. The 5-year-survival rate excluding in-hospital death was 72.5% in AMI, and 89.6% in UAP. The 5-year-cardiac event-free rate was 77% in AMI and 89.4% in UAP. The overall survival rate, and cardiac event-free rate, at 5 years was 80.8%, and 83.8%, respectively. In conclusion, for ACS cases, especially UAP cases of LMT, in which symptoms, findings of ischemia and hemodynamics are stabilized by medical intervention including IABP; emergency surgery could be avoided immediately after coronary angiography. Recovery in the ischemic myocardium is intended by IABP, and urgent surgery should be performed after sufficient and precise preoperative examinations. An improvement not only in the perioperative but also long-term results can be expected by performing complete revascularizations.

[Mitral valve repair for a broad prolapse in the high posterior leaflet].

We report a mitral valve repair for a broad prolapse in the high posterior leaflet. Prolapse in the high redundant posterior leaflet with elongation of the chordae had caused the severe mitral valve regurgitation in a 45-year-old man. At operation, the prolapsed portion of the middle scallop was quadrangularly resected in 22 mm wide and 17 mm high. We combined the sliding leaflet technique with the posterior leaflet folding plasty to reduce the height of the posterior leaflet and to lessen the degree of mitral annular plication. Mitral valve regurgitation disappeared after the operation. No left ventricular outflow obstruction associated with systolic anterior motion and no injury to the left circumflex artery were confirmed. These procedures after a broad resection of the high posterior leaflet could successfully prevent systolic anterior motion and injury to the left circumflex artery, and reduce the stress on the suture line of the leaflet.

Successful valve-sparing in aortic root reconstruction under endoscopic guidance.

OBJECTIVE: Aortic insufficiency (AI) associated with ascending aneurysm can be corrected by valve-sparing aortic root reconstruction ('David' reimplantation, 'Yacoub' remodeling). Intraoperative endoscopic evaluation in the aortic root may help to clarify the procedure and to access competence of the preserved valve. METHODS: Following cross-clamping of the ascending aorta, an endoscopy was inserted into the proximal aortic root. Perfusion of crystalloid cardioplegia enabled the visualization of the pressure-loaded valve in the closed position. Conventional macroscopic evaluation would have overlooked valve prolapse because of a release from perfusion pressure. Valve coaptation was imaged directly before and after the valve-sparing procedure. A total of 17 patients underwent aortic root reconstruction under endoscopic guidance. Indications of the valve-sparing were determined with endoscopic findings. The degree of AI before and after the surgery was evaluated by aortography and scored (0, none; 1 trivial; 2, mild; 3, moderate; 4, severe). RESULTS: Remodeling was employed to eight patients and reimplantation to four. The other five patients were replaced with prosthetic valved-conduit. There was no early and late mortality. Before and after the valve-sparing surgery, grades of AI were significantly reduced. Three patients who underwent reimplantation procedure required late valve replacement for late progression of AI, however, none of the patients with remodeling required reoperation. CONCLUSION: Introduction of an endoscopy successfully reduced postoperative AI and clarified indications and limitations of valve-sparing aortic root operations.

[A case report of mycotic aneurysms of descending thoracic aorta].

A rare case of mycotic aneurysms of descending thoracic aorta is presented. A 63-year-old man was admitted with history of persistent high fever and loss of consciousness to our hospital. On admission, there were elevated WBC and CRP. Blood and spinal fluid cultures revealed growth of Streptococcus pneumonia. Despite of antibiotic therapy for meningitis and bacteremia, inflammatory sign continued, and new abnormal shadow appeared on chest X-ray. Chest CT and aortography showed two aneurysms of descending thoracic aorta. In an emergency operation, there was no abscess formation around the aneurysms. Aneurysms were excised en bloc without opening aneurysms followed by in situ Dacron tube graft replacement. The patient has been doing well without infection.

Clinical evaluation of the centrifugal pump in open heart surgery: a comparative study of different pumps.

The centrifugal pump is now widely used in open heart surgery for its clinical benefits related to the blood elements and the coagulation system. The purpose of this study was to compare the clinical performances of and the outcomes offered by 4 types of centrifugal pumps. For each pump, we investigated the effects on the blood elements, coagulation system, complements, and immunoglobulins during open heart surgery. Four types of centrifugal pumps were used: the HPM-15 (Nikkiso Co.), the Capiox (Terumo Co.), the Lifestream (St. Jude Medical Co.), and the BP-80 (Medtronic, BioMedicus Co.). The platelet count, lactate dehydrogenase (LDH), antithrombin III (AT III), thrombin-antithrombin complex (TAT), complements (C3, C4, and CH50), and immunoglobulins (IgG, IgA, and IgM) were measured before and after cardiopulmonary bypass (CPB). The platelet count was decreased more significantly by the HPM-15 than by any of the other pumps. The other parameters showed no difference among the 4 pumps. In clinical use, each of the 4 types of centrifugal pumps was safe.

Clinical use of centrifugal pumps and the roller pump in open heart surgery: a comparative evaluation.

Centrifugal pumps have been used widely as the main pump in open heart surgery to reduce damage to blood elements and to reduce the activation of the coagulation system. The purpose of this study was the evaluation and comparison of the effects of two types of centrifugal pumps and of one type of roller pump on blood elements, the coagulation system, complements, and immunoglobulins. Two types of centrifugal pumps (Lifestream; St. Jude Medical, Chelmsford, Massachusetts; and BP-80: Medtronic, BioMedicus, Inc., Eden Prairie, Minnesota, U.S.A.) and one roller pump (Mera Co.) were used separately as the main pump for cardiopulmonary bypass (CPB) in 29 patients. Platelet counts, lactate dehydrogenase, antithrombin III, thrombin-antithrombin complex (TAT), complements (C3, C4, and CH50) and immunoglobulins G, A, and M values were measured before and after CPB and compared. Values, except those for TAT, showed no significant difference among the three groups. The TAT values increased less in each of the centrifugal pump groups than in the roller pump group. This finding suggests that thrombin synthesis might be suppressed by the use of a centrifugal pump.

[Mitral valve repair by the sliding leaflet technique employed for a broad prolapse in the posterior leaflet: a case report].

We report a case of a broad prolapse in the posterior leaflet successfully treated by a mitral valve repair by the sliding leaflet technique. The mitral valve regurgitation was caused by a rupture and elongation in the chordae supporting the middle scallop. First 3 cm of the leaflet was quadrangularly resected, then the posterior leaflet was detached from the annulus. Suture annuloplasty of that portion was performed and then the posterior leaflet was reattached to the annulus. Finally a Carpentier-Edwards annuloplasty ring was sutured in position. A postoperative study revealed no regurgitation. The sliding leaflet technique seemed to be effective to reduce tension in the isovolumic stress area caused by covering the broad gap left by the resected leaflet. When mitral valve repair by the sliding leaflet technique is performed, we recommend the use of an annuloplasty ring to decrease the stress on the suture line, to remodel the annular configuration and to prevent annular dilatation.

[A case report of mitral valve plasty for traumatic mitral regurgitation].

A 64-year-old man was admitted to our hospital with a chief complaint of general fatigue on June 24, 1993. He had no history of rheumatic fever but bruised in the chest in September 1990. After that, his systolic murmur was noticed at the apex and echocardiogram showed the posterior chordal rupture of mitral valve. Mitral valve plasty was performed successfully.

[Experience with 2 cases of traumatic diaphragmatic hernia occurred at the same time].

Two cases of traumatic diaphragmatic hernia (TDH) which occurred at the same traffic accident, are reported. The first case, a plain chest X-P was diagnostic of TDH. With thoracotomy and additional laparotomy, lacerated diaphragm was repaired. The second case, continual observation on plain chest X-P was useful to suspect TDH, and thoracoscopy was diagnostic. With thoracotomy diaphragm was repaired. Two patients recovered well. It has not been reported that two cases of TDH occurred at same trauma. For diagnosis of TDH, chest X-P is useful for suspicion, and thoracoscopy is useful for correct diagnosis. Surgical approach should be decided in consideration of phase, location, and complicated injuries.

Importance of preserving the mitral subvalvular apparatus in mitral valve replacement.

BACKGROUND: This clinical study sought to determine whether mitral valve replacement (MVR) with the preservation of both anterior and posterior chordae tendineae (MVR group II) would be more effective on the improvement of left ventricular regional wall motion than MVR with the preservation of posterior chordae tendineae alone (MVR group I). METHODS: Postoperative left ventricular wall motion was analyzed by a centerline method in three groups of MVR--group I (n = 13), group II (n = 15), and repair group (n = 15)--for mitral regurgitation. Shortening fraction of chordal length was determined in 100 chords, and these chords were divided into five regions. RESULTS: The comparison of postoperative versus preoperative shortening fraction among the three groups revealed that postoperative wall motion improved more strikingly at apical and diaphragmatic regions in the MVR group II and repair group in comparison to the MVR group I. The postoperative shortening fraction at the apical region in the MVR group II was significantly increased in comparison to preoperative shortening fraction (preoperative, 3.68% +/- 1.87%; postoperative, 5.38% +/- 2.33%; p < 0.05). However, postoperative shortening fraction in cardiac base was decreased in the MVR group II as well as other two groups. CONCLUSIONS: The MVR with the preservation of both anterior and posterior chordae tendineae contributed to the improvement of left ventricular regional wall motion in the apical and diaphragmatic regions.

[A case of infective aortic valve endocarditis with splenic abscess].

A 47-year-old woman was admitted to our hospital with high fever, exertional dyspnea and left flank pain. Echocardiography revealed vegetations attached to the aortic valve and moderate aortic regurgitation. Streptococcus anginosus was identified by blood culture examination. Abdominal CT scan showed a low density area in the spleen. The diagnosis of infective aortic valve endocarditis with splenic abscess was obtained. The splenectomy and the aortic valve replacement were performed simultaneously after the treatment with antibiotics. The postoperative clinical course was uneventful. In the case of infective endocarditis with splenic abscess, the splenectomy concomitant with valve surgery should be performed for removing all of the infected tissues.

[A successful case of ischemic cardiomyopathy associated with left ventricular aneurysm and mitral regurgitation].

A 67-year-old female patient underwent a left ventricular aneurysmectomy and mitral valve replacement for ischemic cardiomyopathy. The replacement was done through left ventricle rather than left atrium. She had heart failure of NYHA class IV despite aggressive medical therapy. Preoperative examination revealed a left ventricular aneurysm and mitral regurgitation of grade II with markedly reduced ventricular function (LVEF 17%). Mitral valve replacement through left ventricle preserving chorda of the mitral valve is a promising method to eliminate regurgitation and shorten the cardiac ischemic time.

[Clinical study on the ideal temperature of blood cardioplegic solution in coronary artery bypass graft surgery].

The effect of myocardial protection in coronary artery bypass graft surgery was evaluated from enzymatic examination and cardiac function to clarify the ideal temperature of blood cardioplegic perfusate (BCP). The surgical cases were divided into two groups from the temperature of BCP; 8 degrees C BCP in 64 cases (Group I) and 20 degrees C BCP in 64 cases (Group II). Peak total creatine-Kinase (CK) and CK-MB fraction were significantly elevated in Group I than in Group II. The value of CK-MB was 79 +/- 79 IU/L in Group I and 37 +/- 26 IU/L in Group II (p < 0.01). The parameters of cardiac function were measured from radio-isotope (RI) ventriculography in the 35 cases with depressed ejection fraction and elevated left ventricular end-diastolic pressure (17 cases in Group I and 18 cases in Group II). Postoperative parameters such as ejection fraction, first third ejection fraction, peak ejection rate and early diastolic peak filling rate improved more significantly than preoperative values in Group II, although these parameters did not improve in Group I. From these results, 20 degrees C BCP provided excellent myocardial protection to arrested heart during coronary artery bypass surgery probably because of decreased viscosity of BCP and adequate oxygen carrying capacity to myocardium.