Mitral valve repair for double-orifice mitral valve with flail leaflet: the usefulness of real-time three-dimensional transesophageal echocardiography.

We describe a 66-year-old man who required an operation for severe mitral regurgitation associated with a double-orifice mitral valve. Real-time 3-dimensional transesophageal echocardiography clearly demonstrated a double-orifice mitral valve with a central fibrous bridge. A flail posterior leaflet was observed on the anterolateral mitral valve orifice. Mitral valve repair using P1 triangular resection, anterolateral commissure plication, and ring annuloplasty with Duran band (Medtronic, Minneapolis, MN) was successfully performed. Postoperative real-time 3-dimensional transesophageal echocardiography demonstrated a double-orifice mitral valve without regurgitation or stenosis.

[Successful surgical treatment for Stanford type A acute aortic dissection complicating a loss of consciousness; report of a case].

An 88-year-old man was transfered to our hospital due to loss of consciousness. Intravenous dopamine was initiated for a shock status and endotracheal intubation was performed. Computed tomography with contrast medium showed Stanford type A acute aortic dissection complicating cardiac tamponade. Because cardiac drainage was not effective, we performed an emergent operation. Intrapericardial cavity was filled with clotted blood. Prosthetic graft replacement of ascending aorta was performed successfully under deep hypothermic circulatory arrest. His clinical course was uneventful and he was discharged on foot without any neurologic deficits.

[Coronary artery bypass grafting in a patient with systemic lupus erythematosus, scleroderma and secondary antiphospholipid syndrome].

A 71-year-old patient with systemic lupus erythematosus, scleroderma and secondary antiphospholipid syndrome underwent coronary artery bypass grafting using cardiopulmonary bypass for angina pectoris. Postoperatively, new onset of thrombotic complications including neurological deficits was not recognized. She was discharged without any complications.

Surgical correction of isolated unilateral absence of right pulmonary artery.

A 2-year-old girl with isolated unilateral absence of right pulmonary artery is described. Catheterization at 5 months demonstrated hypoplastic right pulmonary artery by pulmonary venous wedge angiography, and the patient underwent right Blalock-Taussig shunt and angioplasty of right pulmonary artery with autologous pericardial roll as an initial step. At 2 years, she underwent anastomosis of right pulmonary artery to main pulmonary artery with an autologous pericardial tube. Postoperative computed tomography showed a patent reconstructed right pulmonary artery.

Mitral valve replacement via right thoracotomy approach for prevention of mediastinitis in a female patient with long-term uncontrolled diabetes mellitus: a case report.

A 76-year-old woman with a history of percutaneous transvenous mitral commissurotomy and repeated hospital admissions due to heart failure was referred for an operation for severe mitral valve stenosis. She presented with hypertension, hyperlipidemia and cerebral infarction with stenosis of right internal carotid artery, retinopathy, neuropathy and nephropathy caused by long-term uncontrolled diabetes mellitus, hemoglobin A1c of 9.4%, and New York Heart Association (NYHA) functional classification of 3/4. Echocardiography revealed severe mitral valve stenosis with mitral valve area of 0.6 cm2, moderate tricuspid valve regurgitation, and dilatation of the left atrium. Taking into consideration the NYHA functional classification and severe mitral valve stenosis, an immediate surgical intervention designed to prevent mediastinitis was performed. The approach was via the right 4th thoracotomy, as conventional sternotomy would raise the risk of mediastinitis. Postoperative antibiotics were administered intravenously for 2 days, and signs of infection were not recognized.In patients with long-term uncontrolled diabetes mellitus, mid-line sternotomy can easily cause mediastinitis. The choice of operative approach plays an important role in preventing this complication. In this report, the importance of the conventional right thoracotomy for prevention for mediastinitis is reviewed.

Surgical case of partial anomalous pulmonary venous connection to superior vena cava with cor triatriatum: Williams' modification and excision of diaphragm.

We experienced a successful pediatric surgical case of partial anomalous pulmonary venous connection to the superior vena cava with cor triatriatum. Echocardiography and multidetector-row computed tomography showed partial anomalous pulmonary venous connection (right upper pulmonary vein connected to the high superior vena cava) and atypical cor triatriatum (analogue to type III-A2 of Lucas-Schmidt classification: left upper pulmonary vein had dual connection to the innominate vein via vertical vein and the accessory chamber). At 8 years of age, the male patient underwent extracardiac right atrial pedicle repair of partial anomalous pulmonary venous connection to the superior vena cava (Williams' modification) and excision of the diaphragm between the accessory chamber and the left atrium simultaneously. The postoperative course was uneventful in normal sinus rhythm and there was no stenosis of newer drainage root from right upper pulmonary vein.

Vacuum-assisted closure for mediastinitis after pediatric cardiac surgery.

Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.

Conversion from total cavopulmonary shunt to Fontan circulation: improved cyanosis with an 11-year interval.

We experienced a conversion case from total cavopulmonary shunt (TCPS) to the Fontan circulation with an 11-year interval in the left isomerism and an interruption of the inferior caval vein. Marked cyanosis (pulse oximetry measuring 74%) progressed 8 years after TCPS because of the prominent development of bilateral pulmonary arteriovenous fistula (PAVF), which was diminished after the Fontan conversion, and recent pulse oximetry measured 95% 22 months after the conversion. We believe that this report is a case with the longest interval from TCPS to Fontan in which PAVF was diminished and marked cyanosis was improved.

Successful in situ treatment of infected aortic arch prosthesis by omental wrapping.

A 67-year-old man who underwent total aortic arch graft replacement with coronary artery bypass grafting developed postoperative Serratia mediastinitis. Re-operative debridement and irrigation were carried out. An infected aortic arch prosthesis was successfully treated by in situ disinfection followed by complete omental wrapping.

The impact of mitral valve surgery combined with maze procedure.

OBJECTIVE: Recent studies indicated that successful maze procedure for atrial fibrillation (AF) adjunct to mitral valve surgery provided a lower incidence of stroke and recurrence of AF. The purpose of this study is to review the 13-year experience of these combined procedures and to identify the risk factors and late outcomes of successful maze procedures compared to failed maze procedures. METHODS: At a single institution, 521 consecutive patients underwent combined maze procedures with mitral valve replacements or valvuloplasties. Three kinds of maze techniques were primarily used: Cox-maze III, Kosakai maze, and cryo-maze procedure. Three months after the operation, 394 patients were in sinus rhythm (Group S) while the remaining 116 patients were in continuous or intermittent AF (Group F), excluding 11 early death patients. Risk factors for Group F were determined by the analysis of all patient demographics. Survival, freedom from stroke, cardiac events, and AF recurrence were analyzed. RESULTS: The proportion of the patients without any other simultaneous procedures was greater in Group S (41% vs 29%, P = 0.02). The distributions of mitral valve surgery and maze procedure techniques were similar in these two groups. A left atrium larger than 70 mm [hazard ratio (HR) = 2.6; 95% confidence interval range 1.04-6.3, P = 0.043], preoperative AF history longer than 10 years (HR = 8.2; 4.5-15.1, P < 0.001) and f-wave voltage in V1 smaller than 0.1 mV (HR = 6.2; 5.0-15.2, P < 0.001) were determined to be risk factors for unsuccessful maze procedures. All the results of Cox proportional hazards models showed superiority in Group S; actuarial survival rates (HR = 2.7; 1.04-7.0, P = 0.035), freedoms from stroke (HR = 3.0; 1.1-8.1, P = 0.003) and cardiac events (HR = 4.3; 2.9-6.1, P < 0.001). Freedom from AF recurrence rate was 98.4% at 5 years and 81.0% at 12 years in Group S, and 73.0% and 60.1% in overall patients. CONCLUSIONS: Patients with successful maze procedures resulted in higher survival rate, greater freedom from stroke and cardiac events. The large left atrium, small f-wave, and long AF duration were significant risk factors for failed maze procedures, suggesting that earlier surgical interventions would result in superior results in mitral valve surgery combined with maze procedure.

Successful treatment of mycotic thoracic aortic aneurysm by in situ graft replacement with omental wrapping.

Mycotic thoracic aortic aneurysm is a fatal disease. We report a case of a 67-year-old man presenting with contained rupture of a mycotic thoracic aortic aneurysm. Urgent in situ graft replacement was successfully performed with omental wrapping to prevent postoperative graft infection.