Delayed-onset systolic anterior motion of the mitral valve after aortic valve replacement for severe aortic stenosis.

Systolic anterior motion (SAM) of the mitral valve after aortic valve replacement (AVR) for severe aortic stenosis (AS) is one of the causes of perioperative left ventricular outflow tract (LVOT) obstruction in older patients. A 90-year-old woman underwent AVR with a 19-mm bioprosthesis for symptomatic aortic valve stenosis. Preoperative transthoracic echocardiography (TTE) showed left ventricular hypertrophy, with LVOT obstruction and mild mitral regurgitation (MR). Intraoperative transesophageal echocardiography and postoperative TTE showed that the degree of MR was unchanged after surgery. The patient's postoperative course was uneventful. However, she developed shortness of breath 6 months after discharge. A subsequent TTE showed significant LVOT obstruction and SAM, which resulted in moderate to severe MR. Because of the patient's advanced age, cibenzoline was administered to decrease the left ventricular pressure gradient (LVPG) and improve the left ventricular diastolic function. Two months after administration of cibenzoline, a TTE showed decreased LVPG, trivial MR, and the absence of SAM. This case clearly demonstrated that cibenzoline improved the SAM of the mitral valve that arose after AVR for AS in a remote postoperative period.

Infected Aortic Aneurysm Secondary to Pyogenic Flexor Tenosynovitis from Streptococcus pyogenes.

Infected aortic aneurysms are rare, and have a high mortality rate. Although not a major pathogen, Streptococcus pyogenes has been reported to cause infected aortic aneurysms. In the present case, the patient was hospitalized for pyogenic flexor tenosynovitis with S. pyogenes bacteremia. Despite drainage of the abscess around the flexor tendon and effective antimicrobial therapy, infected aneurysms developed in the abdomen and ascending aorta. Because of their rapid enlargement, these aneurysms were treated with in situ reconstruction. Although rare, the possibility that S. pyogenes is the causative pathogen of infected aortic aneurysms should be considered.

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area.

BACKGROUND: This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. METHODS: The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. RESULTS: In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p = 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p = 0.645) and 80.7% and 77.4% (p = 0.300), respectively. CONCLUSIONS: In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

The off-pump technique in redo coronary artery bypass grafting reduces mortality and major morbidities: propensity score analysis of data from the Japan Cardiovascular Surgery Database†.

OBJECTIVES: The benefits of off-pump coronary artery grafting (OPCAB) have been demonstrated. Especially in patients with a high number of comorbidities, redo coronary artery bypass grafting (CABG) remains a difficult entity of CABG, because patients are likely to have multiple risk factors and often have diseased patent grafts with adhesions. The aim of the present study was to evaluate the effects of the OPCAB technique in redo CABG on mortality and morbidity using data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS: We analysed 34 980 patients who underwent isolated CABG between 2008 and 2011, as reported in the JCVSD. Of these, 1.8% of patients (n = 617/34980) had undergone redo CABG, including those who underwent OPCAB (n = 364; 69%) and on-pump CABG (n = 253; 41%). We used propensity score (PS) matching with 13 preoperative risk factors to adjust for differences in baseline characteristics between the redo OPCAB and on-pump redo CABG groups. By one-to-one PS matching, we selected 200 pairs from each group. RESULTS: There were no significant differences in patient background between the redo OPCAB and on-pump redo CABG groups after PS matching. There was no significant difference in the mean number of distal anastomoses after matching (2.41 ± 1.00 vs 2.21 ± 1.04, P = 0.074); nevertheless, the mean operation time was significantly shorter in the redo OPCAB than the on-pump redo CABG group (353.7 vs 441.3 min, P < 0.00010). Patients in the redo OPCAB group had a lower 30-day mortality rate (3.5 vs 7.0%, P = 0.18), a significantly lower rate of composite mortality or major morbidities (11.0 vs 21.5%, P = 0.0060), a significantly lower rate of prolonged ventilation (>24 h) (7.0 vs 15.0%, P = 0.016), a significantly shorter duration of intensive care unit (ICU) stay (ICU stay ≥ 8 days) (7.0 vs 14.5%, P = 0.023) and a significantly decreased need for blood transfusions (71.5 vs 94.0%, P < 0.00010) than patients in the on-pump redo CABG group. CONCLUSION: The off-pump technique reduced early operative mortality and the incidences of major complications in redo CABG.

Upgrading redo coronary artery bypass graft by recycling in situ arterial graft.

We present a case of redo coronary artery bypass grafting (CABG) in which a single internal thoracic artery (ITA) graft was upgraded to a bilateral ITA graft by recycling a left ITA graft, anastomosed to the left anterior descending artery in primary CABG performed 17 years previously. During redo CABG, we dissected the left ITA, reused it in situ for the circumflex artery, and used the right ITA to the left anterior descending artery for a bilateral ITA graft. All grafts remained patent 2 years after redo CABG. Recycling ITA grafts may enable upgrading to bilateral ITA grafting during redo CABG.

Prediction of early postoperative cerebral hemorrhage in infective endocarditis patients using magnetic resonance imaging.

OBJECTIVE: To evaluate the relationship between preoperative magnetic resonance imaging (MRI) findings and the occurrence of postoperative intracranial hemorrhage (ICH) in infective endocarditis (IE) patients. METHODS: Between 2002 and 2012, 30 IE patients required surgical intervention. Four patients developed and 26 patients did not develop postoperative ICH. All patients underwent preoperative brain MRI. The presence of acute brain infarction was detected by diffusion-weighted imaging (DWI), and cerebral microbleeds were detected by T2*-weighted imaging. RESULTS: Two ICH(+) patients died of stroke. Preoperative patient characteristics and operative results were not significantly different. Regarding MRI findings, the presence of cerebral microbleeds or acute brain infarction alone was not significantly different between the two groups (100 vs. 29.6 %, p = 0.07; 75.0 vs. 38.5 %, p = 0.37, respectively). The concurrent presence of cerebral microbleeds and acute brain infarction was significantly correlated with the development of major ICH (75 vs. 14.8 %, p = 0.04). In multiple logistic regression analyses, the concurrent presence of cerebral microbleeds and acute brain infarction on MRI was an independent predictor of major postoperative ICH (p = 0.03, odds ratio 16.5, 95 % confidence interval 1.35-201.3). CONCLUSION: The combination of T2*-weighted MRI and DWI may be useful to evaluate the risk of IE patients developing major postoperative cerebral bleeding.

A novel technique of aortic root reconstruction for extensive endocarditis: the pericardial skirt technique.

Extensive aortic valve endocarditis requires thorough debridement of the paravalvular tissue, and reconstruction of the destroyed aortic root can be technically difficult. In the present report, we describe a simple technique for aortic root reconstruction. In this technique, a doughnut-shaped bovine pericardial sheet (skirt) is attached to the proximal end of a valved conduit and then sewn onto the destroyed aortic annulus. Because skirt flexibility facilitated excellent adaptation to the irregular annular plane, we did not encounter any severe bleeding from the proximal anastomosis of the valved conduit in any of the cases. We believe that our procedure may be beneficial for aortic root reconstruction in patients with extensive endocarditis.