Surgical repair of tetralogy of Fallot in a 78-year-old woman: a case report.

BACKGROUND: Tetralogy of Fallot is a congenital heart disease mostly diagnosed and treated in early childhood. However, there are some adult cases receiving treatment. CASE PRESENTATION: We describe a 78-year-old Japanese woman who presented with severely hypertrophic right ventricle, ventricular septum defect, overriding aorta, and severe infundibular stenosis in the right ventricular outflow tract. As hypoxemia was mild and daily exertion was sufficiently possible, home oxygen therapy was introduced. After 1 month, she was referred because of a positive blood culture. The blood culture test was positive four times, therefore, the antibacterial drug was administered according to active infective endocarditis. SpO2 repeatedly decreased during hospitalization, thus oxygen was needed. As there were infective endocarditis onset and progressive hypoxemia, we planned a surgical correction. CONCLUSION: Tetralogy of Fallot was diagnosed and successfully treated with complete surgical correction, and the development of infective endocarditis was the definitive indication for surgery at this late age.

Intracardiac Three-Dimensional Image as Surgical Decision-Making Tool of Congenital Heart Disease.

This study aimed to evaluate the anatomical reproducibility of a preoperative intracardiac 3D image (IC image) created using computed tomography, and to investigate its usefulness as a surgical decision-making tool. Between 2012 and 2022, ventricular septal defect (VSD) patients, and double outlet right ventricle (DORV) or transposition of the great arteries (TGA) with pulmonary stenosis (PS) patients who underwent cardiac surgery and had preoperative computed tomography were enrolled. SYNAPSE VINCENT® (Fujifilm) was used to create an IC image which was analyzed retrospectively. In 14 VSD patients, the diagnostic consistency rate in the Soto classification with intraoperative findings was 100% (14/14) for IC image versus 64% (9/14) for transthoracic echocardiography (P = 0.04). The defect size showed a higher correlation coefficient with IC image (0.837, P = 0.001) than with transthoracic echocardiography (0.567, P = 0.034). In 11 DORV/TGA with PS patients, the diagnostic consistency rate in the Lev classification was 100% (9/9) for IC image versus 77% (7/9) for transthoracic echocardiography (P = 0.47). The secondary interventricular foramen (SVF)/left ventricular outflow tract (LVOT) ratio by IC image was significantly smaller in the biventricular-repair group (median 0.71, IQR 0.67-1.06) than in the univentricular-repair group (median 1.79, IQR 1.53-2.42) (P = 0.006). An IC image is useful as a surgical decision-making tool for simple VSDs and complex congenital heart diseases such as DORV or TGA with pulmonary stenosis. The SVF/LVOT ratio determined from the IC image may be a useful indicator for avoiding LVOT obstruction.

Untreated atrial septal defect after intracardiac repair for tetralogy of Fallot.

Tetralogy of Fallot was repaired previously in a preschooler through right ventriculotomy, providing excellent exposure for ventricular septal defect closure and right ventricular outflow tract obstruction relief. Herein, we describe the preschooler as a 50-year-old man with untreated atrial septal defect found at pulmonary valve replacement in the remote period after tetralogy of Fallot repair. It was inferred intraoperatively that the previous tetralogy of Fallot was repaired only through right ventriculotomy, and atrial septal defect closure was performed together with pulmonary valve replacement.

[Cardiac Strangulation Induced by Epicardial Pacemaker Leads Causing Heart Failure;Report of a Case].

A 5-year-old girl has a history of epicardial VVI-pacemaker implantation due to congenital heart block at the age of 2 months. Five years later, she developed heart failure at the same time of battery depletion. The chest X-ray indicated the loop formation of the epicardial leads and the echocardiogram demonstrated paradoxical movement of ventricles. The 3-dimensional computed tomography finally revealed strangulation of biventricular apex caused by loop of the leads. She underwent reoperation. Cardiac strangulation was relieved by total removal of the loop and repositioning of right atrial and ventricular electrodes in a gentle curve of the leads. She was discharged and doing well. Cardiac strangulation is a rare, but it can be lethal. Therefore epicardial pacemaker leads should not be positioned around the ventricle with excessive redundancy.

Safety and effectiveness of tolvaptan for fluid management after pediatric cardiovascular surgery.

BACKGROUND: Postoperative fluid management is important after open heart surgery, because cardiopulmonary bypass evokes an abnormal inflammatory response and increases vascular permeability, especially in pediatric patients. We assessed the safety and effectiveness of tolvaptan for management of postoperative fluid retention after congenital heart surgery. METHODS AND RESULTS: This retrospective study analyzed data from 43 children with uncomplicated congenital heart disease who underwent open heart surgery between September 2013 and August 2016. The patients were divided into two groups. Group N (n = 18; September 2013 through May 2014) received the conventional oral diuretics alone, and Group T (n = 25; June 2014 through August 2016) received a single dose of tolvaptan (0.45 mg/kg) in addition to the conventional oral diuretic therapy. Data were collected, while patients who received intensive care were assessed and compared between groups. Add-on tolvaptan use was associated with increased urinary output standardized by body weight (54.3 ± 4.5 vs 47.3 ± 19.1 mL/kg; p = 0.043), decreased additional intravenous diuretic dose standardized by body weight (0.26 ± 0.23 vs 0.62 ± 0.48 mg/kg; p = 0.001), and a smaller decrease in central venous pressure (1.3 ± 2.7 vs 1.9 ± 3.8 mmHg; p = 0.019). Laboratory analysis showed that electrolyte concentrations in blood and urine did not significantly differ between groups. CONCLUSIONS: Tolvaptan appears to be effective and safe for management of postoperative fluid retention after congenital heart surgery.

Open-square technique using a novel pre-cuffed, spiral-ringed conduit for the Norwood procedure.

To avoid stenotic conduit events, 2 modifications were added to Norwood reconstruction with a right ventricle-to-pulmonary artery conduit: open-square insertion of a proximal conduit end and use of a pre-cuffed, spiral-ringed conduit. Three consecutive patients treated with this technique successfully underwent bidirectional Glenn with no stenotic events. These modifications are beneficial and safe.

Enantioselective total syntheses of pygmaeocins B and C.

The first enantioselective total syntheses of pygmaeocins B and C have been accomplished using an efficient and highly diastereoselective intramolecular Heck cyclization for the construction of a quaternary stereogenic center and the functionalized A-ring of the natural products as the key step.

Diastereoselective intramolecular carbamoylketene/alkene [2 + 2] cycloaddition: enantioselective access to pyrrolidinoindoline alkaloids.

A novel and highly diastereoselective intramolecular carbamoylketene/alkene [2 + 2] cycloaddition has been developed, and the methodology was successfully applied to the enantioselective syntheses of (-)-esermethole and Takayama's intermediate for (+)-psychotrimine.

Total synthesis of debromoflustramines B and E based on the intramolecular carbamoylketene-alkene [2 + 2] cycloaddition.

Total synthesis of debromoflustramines B and E has been accomplished by using a platinum-catalyzed addition reaction of o-aminophenylboronic acid with the allene and an intramolecular carbamoylketene-alkene [2 + 2] cycloaddition for the construction of the basic carbon framework of the target alkaloids as the key steps.

Bidirectional Glenn procedure for an infected modified Blalock-Taussig shunt.

A 1-month-old girl underwent right modified Blalock-Taussig shunt (mBTS) for pulmonary atresia with hypoplastic right ventricle. Five months after palliation, she suffered from sepsis and progressive desaturation following otitis media. Computed tomography and angiography revealed a pseudoaneurysm surrounding the mBTS graft. After stabilization of the infection, we performed pseudoaneurysm resection, shunt-graft removal, and the bidirectional Glenn (BDG) procedure under cardiopulmonary bypass. Her condition improved, and she was discharged on the 17th day after surgery. When parameters for the partial right heart bypass should permit, the BDG procedure can be a beneficial recovery procedure for the cases of infected pseudoaneurysm after mBTS in Fontan candidates.

Literature survey on epidemiology and pathology of cardiac fibroma.

BACKGROUND: Although cardiac fibroma has been regarded as benign tumor, it presents various symptoms and may lead to death. Unfortunately, only a few studies have reported the epidemiology, embryology, and histopathology of the tumor, and the factors predicting poorer outcome are still obscured. METHODS: In July 2011 we searched for English and Japanese cases of cardiac fibroma using the PubMed and IgakuChuoZasshi databases. We then extracted and sampled raw data from the selected publications in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) style as much as was possible. RESULTS: Details of a total of 178 patients with cardiac fibroma were retrieved. The mean age was 11.4 years (median: 2.8 years). Tumor sizes ranged from 8.0 to 150.0 mm (mean 53.1 mm). The left ventricle was found to be the most common site associated with the tumor at a rate of 57.3%, followed by the right ventricle, and interventricular septum. The highest mortality was found in patients with septal involvement (58.6%). In all, 111 patients survived among the 160 patients with a recorded outcome. A younger age of the patient at the time of diagnosis was associated with a decreased survival rate. In addition, a significant positive association was found between ages for patients younger than 17 years of age and the diameter of the tumor at the time of diagnosis (r = 0.341, P = 0.006). CONCLUSIONS: Both the younger age of patients at the time of diagnosis and septal involvement can be regarded as factors significantly indicating a poor prognosis. Furthermore, our statistical analyses support the following hypotheses. First, the high ratio of tumor-to-heart size may generate low cardiac output and therefore lead to poor outcome. Second, the ratio of the sites where cardiac fibroma occurred corresponds with the ratio of the muscular weight of the cardiac chamber. Third, cardiac fibroma involving the interventricular septum more frequently induces conduction system disease.

Fontan conversion with novel direct ablation after childbirth: report of a case.

A 38-year-old woman underwent atriopulmonary Fontan surgery at age 18 years and subsequently successfully delivered a girl by cesarean section at age 34. Her condition later deteriorated due to atrial tachyarrhythmia and progressed to New York Heart Association (NYHA) class IV heart failure. Her treatment, at age 36, comprised total cavopulmonary connection conversion, direct right atrial ablation with bipolar radiofrequency devices, the creation of an atrial septal defect, and placement of a dual-chamber permanent pacemaker. Three years after the conversion, her condition has improved to NYHA class I.

Stent graft implantation combined with coil embolization and external-internal iliac artery bypass surgery: report of a case.

A 73-year-old male patient was found to have an abdominal aortic aneurysm complicated with bilateral common iliac artery aneurysms. He also had hepatitis C, chronic liver cirrhosis (Child-Pugh class B), a rupture of esophageal varices, hepatocellular carcinoma, and intractable ascites. The functions of other systemic organs were also impaired. We first performed a right internal iliac artery coil embolization prior to stent graft implantation combined with a left external-internal iliac artery bypass. These additional procedures allowed for safe treatment with stent graft implantation, without any serious complications.

Effect of cryopreservation on cell proliferation and immunogenicity of transplanted human heart cells.

BACKGROUND: Cell preservation is essential for successful cell transplantation and/or tissue engineering. We examined the effects of cryopreservation on the transplantation of human heart cells. METHODS: Cells isolated from human atrial tissues were cultured for 15 days (control group), cryopreserved for 1 week, and rapidly thawed and cultured for 15 days. Proliferation was compared among control and cryopreserved cells or tissues by constructing growth curves. Growth factors, cytokines, biochemical features, and cell cycle phase were measured immediately before and after cryopreservation, and immunogenicity was evaluated from growth curves generated from heart cells after 7 days in mixed-lymphocyte culture. Control or cryopreserved cells were transplanted into rat connective tissues and evaluated histologically 2 weeks later. RESULTS: Cryopreserved cells proliferated more effectively than control cells. Levels of basic fibroblast growth factor and transforming growth factor-ß1 were significantly higher, and those of interleukin (IL)-6 and IL-8 were significantly lower after cryopreservation. Fewer peripheral blood lymphocytes were produced in cryopreserved cells than in noncryopreserved cells, and the cell cycle phase of cryopreserved heart cells shifted primarily to G2 + M from G1 + G0. Noncryopreserved and cryopreserved cells both survived in connective tissue. CONCLUSION: Human atrial cells can be cultured, cryopreserved, and transplanted. Cryopreservation might increase the proliferation of human cells and tissues and also reduce the immunogenicity of heart cells.

[Surgical repair of a total-defect aortopulmonary window in a neonate].

Aortopulmonary window (APW) is a rare congenital heart defect that requires urgent repair, as it can lead to rapid development of pulmonary hypertension. A 6-day-old boy with a total-defect APW was transferred to our hospital and underwent definitive repair on the 15th day after birth. The ascending aorta and pulmonary trunk were divided to create a larger tissue margin on the aortic side for the next seam. Then, the aortic window was sutured and closed directly, while the large pulmonary defect was reconstructed with a fresh autologous pericardial patch. Although peritoneal dialysis was briefly required for acute renal failure due to low output syndrome, his condition improved and he was discharged 22 days after surgery. Six years later, he remains well, without complications or need for medication.

An aortic root pseudoaneurysm that developed after implantation of a rectus abdominis muscle flap to treat an MRSA mediastinitis: a case report.

The occurrence of mediastinitis following synthetic vascular replacement surgery is still associated with an unfavorable prognosis in the treatment of thoracic aortic diseases. This time we report a Bentall procedure that we re-performed to treat an aortic root pseudoaneurysm, which developed after a postoperative mediastinitis. This followed the first Bentall procedure, which was treated by debridement of the focus of infection, continuous lavage, and a two-step rectus abdominis muscle flap implantation. Implantation of a rectus abdominis muscle flap is effective in controlling infection in the treatment of mediastinitis after heart surgery. However, after synthetic vascular replacement surgeries have been performed to treat aortic diseases, especially after aortic root reconstruction surgery, which puts stress on the anastomotic site, consideration should be given regarding the development of hemorrhages and pseudoaneurysms as a result of infection-induced tissue fragilization.

Study of coronary artery bypass using the PAS-Port device: assessment by multidetector computed tomography.

OBJECTIVE: The use of automatic anastomotic devices in coronary artery bypass grafting surgery is associated with lower patency rates in comparison to conventional anastomosis methods. This is thought to be caused by graft curvature occurring after closing of the chest wall. METHODS: We evaluated 39 grafts in 28 patients who underwent off-pump coronary artery bypass surgery using the PAS-Port. After surgery, the proximal anastomotic angle of each stent, graft morphology, and patency were evaluated with axial and sagittal views. RESULTS: The angle for the left anterior descending coronary artery segment was relatively obtuse on the left side of the ascending aorta, and the graft loop formation was not necessary. The angle for the left circumflex coronary artery segment was significantly acute for anastomosis from the upper left side of the ascending aorta. Because grafts are under the constraints of a large loop, graft length tended to become easily excessive or deficient. The angle for the right coronary artery segment was relatively obtuse. The space on the right side of the heart was so narrow that in some cases we had difficulty setting out the appropriate graft location to prevent graft curvature. No bending or stenosis was present in any graft, showing a patency rate of 100%. CONCLUSION: The short-term results of coronary bypass grafting using PAS-Port are satisfactory.

[Effects on proliferation ability of vascular smooth muscle cells by static and/or dynamic cell culture: utility of pre-seeding technique for dynamic cell culture].

OBJECTIVES: Conventional biomaterials are not viable, do not grow, and do not provide contractile effects in cardiac tissue. Foreign synthetic material may become thrombogenic or infected. The most recent cardiac constructs consist of biodegradable material which has the potential to solve these problems. However, dynamic three-dimensional cell culture is necessary because conventional culture is limited to construct tough biografts. METHODS: Vascular smooth muscle cells derived from rat aorta were seeded to poly-L-lactide-epsilon-capro-lactone copolymer in three groups; static culture group (static cell seeding + static cell culture), dynamic culture group (dynamic cell seeding + dynamic cell culture), and pre-seeding group [static cell seeding and culture for 1 week (pre-seeding) + dynamic cell culture]. The dynamic cell culture system used an original spinner flask. The pre-seeding technique used static cell seeding and culture before dynamic culture. The three groups were evaluated by cell proliferation and histologic studies. RESULTS: Vascular smooth muscle cells could be proliferated in/on the biodegradable materials. The pre-seeding group cells grew much more efficiently than the other groups. Very few cells were found in the biodegradable materials with the dynamic groups. However, there were many cells in the materials with the static culture group and pre-seeding group, especially the pre-seeding group. CONCLUSIONS: Dynamic culture is useful for constructing tough biografts by the pre-seeding technique.