Aortic Dissection in Familial Patients with Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common congenital kidney disease. However, reports on occasional cases of aortic dissection in PKD familial patients remain scarce. Herein, we describe rare aortic dissection cases in PKD familial patients (i.e., mother and daughter) and our successful treatment experience. The mother (84 years old) and daughter (53 years old) had a referral to us to treat type A acute aortic dissection. We performed emergency surgery and successfully treated the patients with an artificial graft. For comprehensive evaluation and treatment, ADPKD patients and their families should be screened for aortic diseases.

Successful endovascular treatment of an ascending aortic pseudoaneurysm using an Amplatzer Vascular Plug II.

Pseudoaneurysms are a rare complication of cardiovascular surgery, caused by disruption of the aortic structure (adventitia, media, and intima). Some reports have observed an extremely high mortality rate associated with the open surgical repair of pseudoaneurysms. In elderly or highly frail patients, the use of less invasive procedures is preferable. In this article, we report a case of an octogenarian who had a symptomatic ascending aortic pseudoaneurysm and a history of two sternotomies and present the successful treatment strategy. We treated the patient via an endovascular procedure using an Amplatzer Vascular Plug II (AVP II). After the intervention, the symptoms of the patient resolved. A computed tomography scan performed 1 year after the procedure confirmed the exclusion of the pseudoaneurysm.

Acquired von Willebrand syndrome secondary to mitral and aortic regurgitation.

BACKGROUND: The association of aortic valve stenosis with gastrointestinal bleeding was first described by Edward Heyde in 1958. Since then, there have been numerous case reports of Heyde syndrome in the medical literature worldwide. AIMS: Recently, the definition of Heyde syndrome has been updated to include the combination of aortic valve stenosis, intestinal angiodysplasia, and acquired von Willebrand factor syndrome (AVWS). However, an association between aortic or mitral regurgitation and AVWS is not well established. MATERIALS & METHODS: The present case of a patient with endocarditis-associated severe aortic regurgitation and mitral regurgitation exhibited a clinically significant bleeding diathesis secondary to AVWS. RESULTS: After surgical valve repair, the von Willebrand factor (VWF) activity spontaneously normalized. DISCUSSION: AVWS secondary to cardiovascular diseases occurs from a selective loss of the largest multimers of VWF due to high shear forces in the blood circulation. Although it is established that stenotic valvular lesions are associated with AVWS, there have only been rare reports of regurgitant lesions leading to AVWS. We successfully treated this patient with perioperative supplementation of VWF and factor VIII.

Transplantation of a decellularized mitral valve complex in pigs.

PURPOSE: Conventional mitral valve replacement is associated with the loss of natural continuity of the mitral valve complex. This study evaluated the morphologic/histological characteristics and function of a decellularized mitral valve used as a transplantable graft. METHODS: Hearts excised from pigs were decellularized by perfusion using detergent. Grafts with the mitral annulus, valve, chordae, and papillary muscle isolated from the decellularized heart were then transplanted into recipient pigs. After transplantation, the function of the graft was analyzed through echocardiography. A histological analysis was performed to evaluate the postoperative features of the decellularized graft. RESULTS: The decellularized graft was successfully transplanted in all cases but one. The remaining grafts maintained their morphology and function. They did not exhibit mitral regurgitation or stenosis. Only one animal survived for 3 weeks, and a histological analysis was able to be performed in this case. The transplanted valve was re-covered with endothelial cells. The microvessels in the papillary muscle were recellularized with vascular endothelial cells, and the papillary muscle was completely attached to the papillary muscle of the recipient. CONCLUSION: The early outcome of decellularized mitral graft transplantation was acceptable. This native organ-derived acellular scaffold is a promising candidate for the replacement of the mitral valve complex.

Intracardiac metastasis from unknown uterine cervical cancer with severe thrombocytopenia.

INTRODUCTION: Cardiac metastasis is relatively common in malignant neoplasms, such as lung cancers, breast cancers, melanomas, lymphomas, and leukemias. In contrast, cardiac metastasis of uterine cervical cancer, solitary metastasis to the heart, and tumors inducing severe thrombocytopenia are rare. CASE REPORT: The present patient was a 52-year-old female who was diagnosed with a solitary cardiac tumor prior to uterine cervical cancer and presented with severe thrombocytopenia. Our case had two remarkable aspects: 1) successful treatment under the condition of severe thrombocytopenia in association with the presence of a cardiac tumor, and survival without recurrence of the carcinoma one year after surgery; and 2) a solitary cardiac metastatic tumor larger than the primary uterine cervix carcinoma. COMMENT: we report an extremely rare case of solitary cardiac metastasis of uterine cervical cancer, which wassuccessfully treated. One year after cardiac surgery, the patient is alive without recurrence of the carcinoma.

Off-pump coronary artery bypass grafting in a tracheostomy patient.

In patients who have undergone laryngectomy and have a tracheal stoma, a full median sternotomy substantially increases the risk of wound infection, osteomyelitis, mediastinitis, bleeding, tracheal injury, and poor wound healing. Several reports have been published on sternotomies and skin incisions in tracheostoma patients. Transverse bilateral thoracosternotomy, T-shaped partial sternotomy (manubrium-sparing sternotomy) with transverse skin flaps and anterolateral thoracotomy with partial sternotomy are described as successful approaches to the mediastinum for cardiac surgery. We present a successful case in which off-pump coronary artery bypass grafting (CABG) was performed in a tracheostoma patient using a low T-shaped partial sternotomy and the PAS-Port system. Good long-term results were achieved.

Preserved Vasoconstriction and Relaxation of Saphenous Vein Grafts Obtained by a No-Touch Technique for Coronary Artery Bypass Grafting.

BACKGROUND: To obtain a saphenous vein graft (SVG) for coronary artery bypass grafting (CABG), the benefit of using a no-touch (NT) technique in vascular function has not been fully investigated. Methods and Results: The pathological and physiological functions of human SVGs with a NT technique to preserve the perivascular adipose tissue (PVAT) and ones obtained by using a conventional (CON) technique removing PVAT, were examined. Immunohistochemistry of the section of SVGs showed that the phosphorylation of endothelial nitric oxide synthase in the endothelium of the NT group was more responsive to vascular endothelial growth factor. A myograph of SVGs showed greater contraction with phenylephrine in the NT group. However, the strong contraction was eliminated in SVGs taken by electrocautery. In the 10 patients whose SVGs were taken without electrocautery, endothelial-dependent relaxation with bradykinin was apparently increased in the CON group more than in the NT group. Smooth muscle relaxation with nitroprusside was higher in the CON group at the lower concentrations; however, the relaxation became greater in the NT group at the high concentrations. Therefore, the effect of neutralizing PVAT-released factors in the both groups was further examined. After medium of NT and CON were exchanged in half, relaxation of SVGs was immediately restored in the NT group. CONCLUSIONS: The results suggest that the NT technique preserves the functions of vasoconstriction and relaxation. Also, the presence of PVAT-released vasoconstrictive factors was suspected.

A Calcified Amorphous Tumor Originating in the Aortic Valve Cusp.

Calcified amorphous tumor (CAT) of the heart is a rare nonneoplastic cardiac tumor. The clinical features of cardiac CATs resemble those of other cardiac tumors that include symptoms related to obstruction or embolization. Cardiac CATs have been found in all chambers of the heart but predominantly present in the left ventricle, mitral annulus, and mitral valve. Here we report an extremely rare case of CAT originating in the aortic valve cusp, which may be related to aortic annular calcification and aortic valve stenosis. We successfully treated this patient with tumor resection and aortic valve replacement.

Left ventricular free wall rupture after surgery for ventricular septal rupture.

A 67-year-old man presented with late left ventricular free wall rupture 1 month after an extended sandwich technique through a right ventricular incision for ventricular septal rupture following an inferoposterior acute myocardial infarction. We found that residual infarcted myocardium had led to left ventricular aneurysm formation. A pericardial patch on the left ventricular side at the initial operation should have been secured further from the septal defect using a larger needle. A patch on the left ventricular side is important for complete exclusion of a free wall infarction and for decreasing the stress on the suture line securing the patch.

Three-Dimensional Printing of Life-Like Models for Simulation and Training of Minimally Invasive Cardiac Surgery.

OBJECTIVE: As the use of minimally invasive surgery in cardiothoracic surgery increases, so does the need for simulation and training. We developed a heart model for simulation and training of minimally invasive cardiac surgery, particularly minimally invasive mitral valve repair using our new three-dimensional printing system. METHODS: Digital imaging and communication in medicine data from patient computed tomography, three-dimensional computer-aided design, and three-dimensional printing helped create replicas of the heart and thoracic cavity. A polyvinyl alcohol model material with a texture and physical properties similar to those of heart tissue was initially used in mitral valve replicas to simulate surgical procedures. To develop this material, we mechanically investigated the composition of each part of the porcine heart. RESULTS: We investigated the elastic modulus and breaking strength of the porcine heart. Based on investigation results, the cardiac model was set at rupture strength 20 MPa, elastic modulus 0.17 MPa, and moisture content 85%. This provided a biotexture and feeling exactly like a patient heart. Computed tomography scans confirmed that the model shape was nearly the same as that of a human heart. We simulated minimally invasive mitral valve repair, including ring annuloplasty, chordal reconstruction, resection and suture, and edge-to-edge repair. Full surgery simulations using this model used minimally invasive cardiac surgery tools including a robot. CONCLUSIONS: This life-like model can be used as a standard simulator to train younger, less experienced surgeons to practice minimally invasive cardiac surgery procedures and may help develop new operative tools.

A stepwise aortic clamp procedure to treat porcelain aorta associated with aortic valve stenosis and hemodialysis.

A 62-year-old man was referred for an aortic-valve surgery because of severe aortic stenosis. Thirty years ago, he had undergone a mitral valve commissurotomy and after 9 years, the valve had been replaced by a mechanical valve. He had been undergoing hemodialysis for the past 8 years. A computed tomographic (CT) scan of the chest and abdomen showed a dense circumferential calcification in the wall of the entire thoracic and abdominal aorta, pulmonary artery, and left and right atrium. A conventional aortic-valve replacement was performed. To avoid an embolic event, a "stepwise aortic clamp" procedure was attempted and involved the following: (1) brief circulatory arrest and aortotomy during moderate hypothermia; (2) balloon occlusion at the ascending aorta during low-flow cardiopulmonary bypass (CPB); (3) endoarterectomy by using an ultrasonic surgical aspirator to enable aortic cross-clamping; and (4) a cross-clamp reinforced with felt and full-flow CPB. The patient recovered without any thromboembolic events. Using this procedure to treat a porcelain aorta seemed to reduce the time limit and reduced the risk of brain injury during cardiac surgery.

Off-pump multilayered sutureless repair for a left ventricular blowout rupture caused by myocardial infarction in the second diagonal branch territory.

A left ventricular (LV) free wall rupture is a highly lethal condition. A 78-year-old female, who collapsed while riding a bike, was admitted to our emergency service 7 days after experiencing chest pain. During admission, she had cardiopulmonary arrest. Though cardiopulmonary resuscitation was successful, computed tomography (CT) showed cardiac tamponade. Emergency surgery was then performed. Pericardiotomy revealed a postinfarction blowout rupture of an aneurysm (2 × 3 × 1 cm) on the anterolateral wall of the LV. The top of the aneurysm had a 2-mm wide blowing blood column. Intra-aortic balloon pumping was initiated. An off-pump multilayered sutureless repair using squares of collagen fleece with fibrinogen-based impregnation (i.e., TachoComb) and gelatin-resorcin-formalin glue (GRF glue) was performed. Postoperative coronary angiography revealed occlusion of the second diagonal branch. The patient was free from re-rupture or aneurysm enlargement. An LV blowout rupture, which was caused by myocardial infarction with a limited tear and necrotic area at the second diagonal branch territory, was successfully treated with an off-pump multilayered sutureless repair by using a TachoComb and GRF glue patch. The thickness of the hemostatic material seemed to help control the bulging of the aneurysm and to prevent further LV aneurysm enlargement and re-rupture.

Surgical repair of postinfarction ventricular septal defects-2013 update.

Treatment for postinfarction ventricular septal defect has been improving for several decades. Aggressive resection of the infarcted myocardium (infarctectomy and closure technique) and preserving infarcted myocardium (infarct exclusion technique) have been technically modified. Recent improvement includes use of surgical glue, using an additional patch for infarct exclusion, septal exclusion, sandwich technique via right or left ventricular approach, and endovascular repair. This field still has room for cardiac surgeons to improve surgical strategy and technique.

Midterm results of the "sandwich technique" via a right ventricle incision to repair post-infarction ventricular septal defect.

BACKGROUND: Residual shunting and mortality are problems associated with current surgical repair techniques for post-infarction ventricular septal defects. METHODS: We describe the mid-term results of the "sandwich technique" to repair a post-infarction ventricular septal defect (VSD), performed via a right ventricle incision. Application of direct ultrasonography to the right ventricular wall enables a surgeon to visualize the region, perform an appropriate incision into the right ventricle, and perform a trabecula resection. One patch is placed on the left ventricular (LV) side and the other on the right ventricular (RV) side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches. RESULTS: We had seven consecutive patients. The sandwich technique resulted in geometric preservation of the LV shape. There were no significant leaks, no mortality within a thirty-day postoperative period, and no bleeding problems. Hospital mortality was 14.3% (1/7 cases). Late survival longer than a year was obtained in five cases (71%). The longest patient survival time was nine years. No tissue degeneration was noted. CONCLUSION: This technique may be useful for repairing a post-infarction VSD.

The "loop with anchor" technique to repair mitral valve prolapse.

The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure.

Coronary malperfusion due to flap suffocation after acute type A dissection surgery.

A 24-year-old man presented with chest pain. He was diagnosed as having a type A acute aortic dissection and an annulo-aortic aneurysm. After emergency surgery for an aortic root replacement, his electrocardiogram showed ST-segment depression and T-wave inversion. Echocardiography showed asynergy of the left ventricle without coronary ostial pathology. Heart catheterization revealed no coronary stenosis, but the true lumen of the residual ascending aorta had extreme diastolic narrowing due to flap suffocation. This resulted in coronary malperfusion. The pullback pressure curve confirmed the mechanism. The patient underwent a surgical re-intervention for a total arch repair, which diminished the coronary malperfusion. At a follow-up appointment four years and four months later, the patient was doing well.

Papillary muscle approximation and relocation with a loop technique for mitral complex repair.

Undersized mitral annuloplasty alone is not always sufficient to repair functional mitral regurgitation resulting from left ventricular enlargement; the repair requires a three-dimensional approach to the mitral complex. We introduce a surgical procedure that combines papillary muscle approximation to correct lateral shift and papillary muscle relocation using the loop technique to correct the apical shift with accuracy and technical ease.