Papillary fibroelastoma originating from the atrial septum touching the mitral valve leading to infective endocarditis: a case report.

BACKGROUND: Cardiac papillary fibroelastoma is a rare benign tumor, which is often mistaken for a vegetation. Predominantly asymptomatic, it can cause life-threatening complications. Although rare, mobile papillary fibroelastoma movement between affected valves may hamper valve closure and damage the valve, leading to valvular regurgitation. Endothelial damage increases the risk of developing infective endocarditis. We report a rare case of a highly mobile papillary fibroelastoma originating from the atrial septum touching the mitral valve, leading to mitral regurgitation and, eventually, infective endocarditis. CASE PRESENTATION: A 26-year-old woman with suspected infective endocarditis was referred to us from a previous hospital after having experienced intermittent fever for a month. Before the fever, she had been experiencing exertional dyspnea. In addition, she had undergone a cesarean section two weeks before this admission. A transthoracic echocardiogram showed a mobile mass originating from the atrial septum touching the mitral valve with severe mitral regurgitation. Computed tomography revealed an occluded right profunda femoris artery with an embolus. Infective endocarditis associated with a mobile vegetation with high embolic risk was diagnosed, and urgent surgery was performed. Following the surgery, examinations revealed papillary fibroelastoma originating from the atrial septum and infective endocarditis of the mitral valve. The histopathological examination confirmed that a mass initially thought to be a mobile vegetation was a papillary fibroelastoma. The postoperative course was uneventful except for pericarditis. There has been no recurrence of infective endocarditis or papillary fibroelastoma. CONCLUSIONS: The highly mobile papillary fibroelastoma was thought to have caused both chronic mitral regurgitation and infective endocarditis. Mobile papillary fibroelastomas can cause endothelial damage to nearby valves and predispose patients to infective endocarditis.

Pacemaker Relocation for Radiation Against Overlapping Lung Cancer.

We experienced a patient after pacemaker (PM) implantation who had lung cancer of the left upper lobe that developed just behind the PM. The patient was an 81-year-old man with many complications. Radiation was the only treatment option. The PM had to be moved to another place to avoid direct radiation exposure to it. An epicardial pacing lead was implanted on the right ventricular epicardium, and the new generator was implanted in the abdomen. The patient was treated with a total of 62 Gy of radiotherapy for lung cancer, achieving a temporary shrinkage of the tumor. During the radiotherapy period, the PM functioned well without harmful events. When radiation therapy is needed in cases where the tumor overlaps the PM, relocation surgery using an epicardial pacing lead may be a useful option.

Comparison of patency of single and sequential radial artery grafting in coronary artery bypass.

OBJECTIVES: Sequential radial artery (RA) grafting has the potential to enhance arterial revascularization compared to single grafting. Sequential RA grafting was performed predominantly with a single side-to-side anastomosis. The study aimed to assess if sequential RA grafting improved long-term graft patency compared to single RA grafting. In addition, the anastomotic patencies of side-to-side and end-to-side anastomoses in sequential RA grafting were assessed. METHODS: Two hundred nineteen patients underwent isolated coronary artery bypass grafting with skeletonized RA conduits between 2005 and 2016. Of these, 208 patients underwent radiological graft assessment; thus, 125 and 83 patients underwent single and sequential RA grafting, respectively. The graft and anastomotic patency rates were estimated using the Kaplan-Meier method. RESULTS: The median follow-up period was 9.1 years, and the radiological assessment lasted 5.1 years. The overall RA graft patency rates at 1, 5 and 10 years were 99.4%, 92.7% and 88.1%, respectively. The RA graft patency rate for sequential grafting was similar to that for single grafting (88.7% vs 87.4% at 10 years; P = 0.88). In the stratified analysis of anastomotic patency, the patency rate of side-to-side anastomoses of sequential RA grafting was significantly better than that of end-to-side anastomoses (100% vs 88.7% at 10 years; P = 0.01). CONCLUSIONS: The long-term RA graft patencies of sequential and single grafting were equally high. The anastomotic patency of side-to-side anastomoses of sequential RA grafting was remarkably high. Considering these findings, the RA can be effectively used for multiple arterial coronary revascularizations.

Emergency Endografting for Spontaneous Thoracic Aortic Rupture.

Spontaneous rupture of the thoracic aorta is rare. We present a 76-year-old man who developed spontaneous rupture of the aortic arch associated with massive periaortic hematoma and hypovolemic shock. Because the site of rupture could not be identified, emergency hybrid endovascular aortic repair to shield a long segment of the aorta was performed according to the extent and density of periaortic hematoma on axial CT scans. His blood pressure improved just after deployment of the endograft. Rapid diagnosis by CT and prompt control of aortic hemorrhage by endografting salvaged this patient. Three-dimensional (3D) volume-rendered CT images are useful for identifying the site of aortic rupture, but may not be available in an emergency.

Open Conversion for Type A Ascending Aortic Dissection after Thoracic Endovascular Aortic Repair by the Chimney Graft Technique.

An 83-year-old man with aortic arch aneurysm underwent zone 0 thoracic endovascular aortic repair (TEVAR) by the chimney graft technique with two supra-aortic arch debranching grafts and developed subacute type A ascending aortic dissection. We performed emergency open conversion with circulatory arrest under deep hypothermia. The tip of the chimney graft (around the sino-tubular junction in the ascending aorta) was stiff, making it difficult to inspect the lumen and perform anastomosis. Deep hypothermic circulatory arrest and cutting the endograft stents to mobilize the graft were necessary for secure anastomosis.

Suture Line Dehiscence after Endovascular Aneurysm Repair in a Patient with Marfan Syndrome.

A 68-year-old man with Marfan syndrome developed de-novo leakage after endovascular aneurysm repair of a Dacron graft. Findings at subsequent reoperation suggested that the rebound force on the endograft generated by marked longitudinal deformation in the Dacron graft may have placed stress on the suture line, leading to partial dehiscence. The Dacron graft seemed to provide a stable proximal landing zone. However, the strong tendency of some endograft devices to return to their original shape may apply stress that affected weakened regions of the native aorta.

Recurrent infarctions due to a dome-shaped pannus above the mitral valve prosthesis.

This report describes a unique case of a 56-year-old female who suffered from recurrent stroke after double mechanical valve replacement. During the four years after the surgery, she remained in normal sinus rhythm, received adequate anticoagulation therapy, and no apparent left atrial thrombus was detected. She underwent redo surgery to prevent further stroke after fourth instance of cerebral infarction. Intraoperative findings revealed a 'dome-shaped' pannus formation covering the sewing ring of the mitral prosthesis circumferentially, probably leading to clot formation and repeated infarctions. She has been stroke free for three years after pannus resection.

Aneurysm growth after late conversion of thoracic endovascular aortic repair.

A 69-year-old man underwent thoracic endovascular aortic repair of a descending aortic aneurysm. Three years later, he developed impending rupture due to aneurysmal expansion that included the proximal landing zone. Urgent open surgery was performed via lateral thoracotomy, and a Dacron graft was sewn to the previous stent graft distally with Teflon felt reinforcement. Postoperatively, four sequential computed tomography scans demonstrated that the aneurysm was additionally increasing in size probably due to continuous hematoma production, suggesting a possibility of endoleaks. This case demonstrates the importance of careful radiologic surveillance after endovascular repair, and also after partial open conversion.

Left ventricular external buttress technique for repair of ventricular septal perforation†.

Because of the difficulty in placing a suture-supporting extension to a non-infarcted area, ventricular septal perforation repair in the presence of large myocardial infarctions can give rise to life-threatening tears or ruptures of the left ventricular free wall. We report a case of successful reinforcement of an infarction area from outside of the left ventricle using a large, thick polytetrafluoroethylene felt patch. After surgery, the patient was weaned from cardiopulmonary bypass without difficulty. Postoperative echocardiography revealed no residual shunting and he was alive without complications 3 years after surgery.

Polyglycolic acid sheet with fibrin glue potentiates the effect of a fibrin-based haemostat in cardiac surgery.

BACKGROUND: Hemorrhage from the left ventricle can be critical and sutureless repair using a fibrin-based haemostat (TachoComb) is one effective option. When active hemorrhage is not controlled by the haemostat, we have used a polyglycolic acid (PGA) sheet and fibrin glue in addition. Here we investigated whether the PGA sheet and fibrin glue combined with TachoComb had stronger adhesive properties than TachoComb alone in two experimental models. METHODS: Experiment 1. An airtight circuit that included rabbit skin with holes covered by each type of sealant was gradually pressurized and the burst pressure was recorded automatically (n = 10). Experiment 2. A suture loop was attached to a porcine heart by each sealant, and the peel-off pressure was measured (n = 12). RESULTS: The PGA sheet and fibrin glue combined with TachoComb showed significantly higher adhesive strength than TachoComb alone in both experiments (p < 0.05). CONCLUSIONS: Adding a PGA sheet and fibrin glue increased the adhesive strength of TachoComb in two experimental models, suggesting that this method might be effective for achieving haemostasis in difficult clinical situations.

A papillary-ventricular complex repair technique for functional mitral regurgitation.

The objective of this study was to describe a simple and reproducible papillary-ventricular complex technique for repairing functional mitral regurgitation. To avoid a recurrence of mitral regurgitation subsequent to left ventricular remodelling, we performed papillary muscle plication and papillary muscle and head approximation in combination with relocation of the papillary muscle heads to correct any anterior and or posterior mitral leaflet discrepancy and to preserve the papillary-ventricular complex. Preliminary results in 7 patients showed an encouraging functional improvement following surgery. Future long-term controlled studies in a greater number of patients are required to further assess this novel technique.

Pseudo systolic anterior motion: potential for severe mitral regurgitation after aortic valve replacement.

A 68-year-old man with severe aortic stenosis (AS) and marked left ventricular hypertrophy (LVH), underwent aortic valve replacement (AVR). Preoperative echocardiography demonstrated contact between the anterior mitral leaflet and the interventricular septum during diastole without mitral regurgitation (MR), i. e., "pseudo systolic anterior motion (SAM). " After a mechanical prosthesis had been implanted, severe mitral regurgitation MR and pulmonary hypertension occurred due to "true" SAM of the mitral valve. Despite intensive management, it was difficult to control MR in the acute phase.In the chronic phase, echocardiography revealed the resolution of both SAM and MR. It is suggested that the dramatic reduction of afterload after alleviation of valvular stenosis by prosthetic replacement and increased flow velocity in the left ventricular outflow tract (LVOT) caused SAM with MR. The risk of SAM after AVR should be considered in AS patients with marked LVH, especially in the presence of "pseudo SAM. "

Using a double-plicated posterior leaflet as an anchor for mitral valve replacement: a case of mitral annular calcification.

We present a 62-year-old man with mitral regurgitation whose posterior annulus had severe calcification. Mitral valve replacement was performed by anchoring the cuff on a double-plicated posterior leaflet, and reinforcing with an equine pericardium. The patient is doing well 13 years after surgery with echocardiography showing no problems.

Postoperative renal function after juxtarenal aortic aneurysm repair with simple cross-clamping.

BACKGROUND: We report our 11-year experience of juxtarenal aortic aneurysm (JAA) repair with suprarenal aortic cross-clamping. METHODS: We retrospectively reviewed 51 consecutive JAA repairs performed between 2000 and 2010. In all 51 patients, aneurysms were replaced by prosthetic grafts with simple suprarenal aortic cross-clamping. No special renal protective measures (except inter-renal cross-clamping) were performed during interruption of perfusion to kidneys. For inter-renal cross-clamping, the aortic cross-clamp was placed from below one renal artery to above the other renal artery to maintain hemilateral renal perfusion. This technique was applied in 27 patients (54%). Postoperative complications, renal function, and survival were evaluated. RESULTS: There were no deaths. The average renal ischemia time was 28.9 ± 9.7 minutes. Postoperatively, transient renal failure (defined as an estimated glomerular filtration rate of <30 mL/min/1.73 m(2)) occurred in 14% of the patients. The postoperative decrease of estimated glomerular filtration rate compared with the preoperative value was significantly smaller in the inter-renal clamp group (7.4% ± 16%) than in the suprarenal clamp group (17.5% ± 16%) (P < 0.05, unpaired t test). However, renal dysfunction was temporary and recovered to baseline before discharge with conservative therapy in all patients except one. In addition, renal function was generally preserved at 1 year after surgery. CONCLUSION: Surgical repair of JAA can be performed with simple cross-clamping and an acceptable renal ischemic time, achieving excellent results. Inter-renal cross-clamping reduces renal damage compared with suprarenal cross-clamping.

Combination of familial Barlow's disease with bilateral axillary artery aneurysms in two brothers.

We encountered two brothers with a combination of Barlow's disease and bilateral axillary artery aneurysms who were operated on during their third decade of life. A symmetrical form of true bilateral axillary artery aneurysms is uncommon. Recurrent mitral regurgitation was presented in the older brother with an endocardial defect in the left atrium, suggesting connective tissue fragility. A hereditary connective tissue disorder was strongly suspected because of the similar presentation and an unusual cluster of pathologies in siblings. Careful follow-up is required to detect recurrence of mitral regurgitation or aneurysm formation in other vessels.

Can early aortic root surgery prevent further aortic dissection in Marfan syndrome?

We reviewed 50 patients with Marfan syndrome who underwent surgery for aortic root pathologies comprising a root aneurysm without (n = 25; group A) and with (n = 25; group B) dissection. Aortic root repair included Bentall (n = 37) and valve-sparing (n = 13) procedures. Hospital mortality was 4.0%. Twenty-two patients required 36 repeat surgeries on the distal aorta. The main indication for re-intervention was the dilation of the false lumen. In group A, the distal aorta was stable for up to 7 years, but new dissection developed in 5 (33.3%) of the 15 patients who were followed up for >7 years after the root repair. Actuarial survival including operative mortality was 88.1 and 65.0% at 10 and 20 years, respectively; groups A and B did not significantly differ. Rates of freedom from all-cause death, new dissection or repeated aortic surgery were 60.1, 44.5 and 26.0% at 5, 10 and 15 years, respectively. Group A was significantly better than group B. Prophylactic aortic root repair apparently reduces the likelihood of overall adverse events, but it cannot guarantee the prevention of further aortic dissection. A multidisciplinary approach is needed for patients with Marfan syndrome.

Fenestrated exclusion of the right ventricle for tricuspid atresia and absent pulmonary valve.

The case of a boy who had an absent pulmonary valve, tricuspid atresia, intact ventricular septum, coronary-to-right-ventricular fistula, and dysplasia of the right ventricular free wall is described. At the bidirectional cavopulmonary shunt procedure, the right ventricular free wall was opened and two major fistula orifices to the cavity were closed with sutures. A fenestrated circular patch was placed in the main pulmonary artery and the right ventricular free wall was plicated. The patient then underwent completion for total cavopulmonary connection. Follow-up catheterization showed that the pulmonary artery was partially excluded with minimal pressure wave conduction from the right ventricle, which significantly shrank. This new approach seems to be effective and reproducible in this particular situation.

Multislice computed tomography is useful for evaluating partial anomalous pulmonary venous connection.

Volume-rendered images, derived from multidetector-row computed tomography (MDCT), can facilitate assessment of the morphology of partial anomalous pulmonary venous connection and are thus useful in pre-operative planning to prevent surgical morbidity and assist post-operative evaluations.