Simultaneous pulmonary trunk and ascending aortic aneurysms are very rare, and the role of surgery in this entity is not well defined. We report a rare case of aneurysm of both the pulmonary trunk and the ascending aorta, associated with pulmonary and aortic valve insufficiency in a 17-year-old boy. Cardiac disease had been diagnosed at the age of 5, and at that time, pulmonary and aortic valve insufficiency were found by ultrasound cardiography (UCG). At regular follow-up, both cardiac valve regurgitation and the dilatation of the aneurysm gradually increased. A recent computed tomographic scan revealed that the ascending aortic aneurysm was 55 mm and the pulmonary trunk aneurysm was 60 mm. A UCG also showed severe aortic valve regurgitation and moderate pulmonary valve regurgitation with no pulmonary hypertension. Surgical repair was performed successfully. The aortic valve was replaced with a mechanical valve. The dilated ascending aortic aneurysm was excised and replaced with a Dacron graft. The pulmonary trunk aneurysm was incised longitudinally. The pulmonary valve was tricuspid, and no organic leaflets change was observed. Pulmonary valvuloplasty by commissure plication of the prolapsed cusps was performed. A large portion of the anterior pulmonary aneurysm wall was excised and plicated to reduce the radius diameter. The pathology of the aneurysm wall showed infiltration of inflammatory cells in the tunica media, fragmentation and decrease of elastic fiber, loss of muscular tissue, and increase in collagen fibers. No cystic medial necrosis was observed in the pathologic specimen. The postoperative course was uneventful, and there were no adverse events or complications at 2 years follow-up. The following image study revealed the normal size of the great vessels.

The patient was a 70-year-old woman with severe aortic stenosis and familial hyperlipidemia which was diagnosed in 1994. The patient was admitted as an emergency case due to syncope in 2002. According to ultrasound cardiography (UCG), the pressure gradient of the aortic valve was 120.7mmHg, and the diameter of the aortic valve annulus was 16.7mm. Computed tomography showed porcelain aorta from the annulus of aortic valve to the ascending aorta. On cardiac catheterization, the pressure gradient was 96mmHg, AVA was 0.4cm², and the ejection fraction was 38.7%. Since these findings suggested that conventional AVR was difficult, thoracotomy was performed at the left 5th intercostal level, and apicoaortic valved conduit (valved graft: SJM19HP, Intergard 22mm+Medtronic apical LV connector) was implanted. Postoperative cine MRI showed that most of the cardiac output (87%, 3.29l/min) flowed through the conduit, with the flow via the aortic valve accounting for 13%, 0.51l/min. This surgical procedure can be an effective alternative when conventional AVR is difficult.

This study evaluated factors influencing residual aortic regurgitation (AR) after valve re-suspension surgery for acute type A aortic dissection. From January 1996 through December 2002, 63 patients were treated for acute type A dissection at our institution. Among these 63 patients, pre-and postoperative echocardiograms were available in 38 patients who underwent surgery combined with native aortic valve re-suspension. These 38 patients were divided into 2 groups according to the postoperative AR grade, i. e.: AR group: AR grade≥II (n=6), no-AR group: AR grade≤I (n=32). The severity of pre and postoperative AR was assessed by transthoracic or transesophageal echocardiography. The preoperative diameters of mid ascending aorta and sinotubular junction, and the percentage of the circumference of the dissection at the sinotubular junction level was measured by enhanced CT scan. Preoperative patient backgrounds were similar in both groups. The preoperative AR grade in the AR group was significantly greater than that of the no-AR group (2.25±1.17: 0.69±0.91, p<0.001). The tear was more frequently located in the ascending aorta in the AR group than in the no-AR group (66.7%: 37.5%, p<0.05). The percentage of circumference of the dissection at the sinotubular junction level did not affect the preoperative AR grade, but it did show a tendency to influence the severity of postoperative AR, though the difference was not significant. Three patients (7.9%) had AR grade III at the time of discharge, but did not clinically require further surgical intervention. Preoperative significant AR and the location of the tear in the ascending aorta are associated with postoperative residual AR after aortic valve re-suspension. The percentage of circumference of the dissection at the sinotubular junction level might influence the severity of postoperative AR.

Though preoperative autologous donation is not acceptable for all cases partly because some are preoperatively in a severe condition, intraoperative predonation is possible in almost all cases. We retrospectively evaluated the major factors related to the prevention of homologous blood transfusion by intraoperative predonation in 25 cases following valvular surgery without preoperative autologous donation. Homologous blood was not transfused in 18 cases {Group-(-)} but in 7 cases only after CPB {Group-(+)}. The male/female ratio, type of operation, body weight, CPB dilution, CPB duration, and perioperative change in hematocrit were comparable in the 2 groups. However, the autologous blood pooled before CPB in Group-(-) was significantly more than in Group-(+) (11.3±2.5 vs 7.3±1.8ml/kg, p<0.001). In conclusion, homologous blood transfusion may be prevented by appropriate intraoperative predonation during surgery for valvular disease.

We report a case of redo mitral valve replacement (MVR) for a Björk-Shiley Delrin valve implanted 47 years previously. A 71-year-old man initially underwent MVR for mitral regurgitation at our hospital at the age of 16 years. Following the operation, follow-up examinations were performed at the outpatient clinic and annual transthoracic echocardiogram findings showed only mild mitral regurgitation, with no adverse events noted. However, a transthoracic echocardiogram examination performed 45 years after the operation revealed mild to moderate mitral regurgitation, while dyspnea with exertion was also noted at that time. As part of a more detailed examination, transesophageal echocardiogram results showed moderate transvalvular leakage. Redo MVR was subsequently performed under the diagnosis of prosthetic valve dysfunction. Analysis of the explanted prosthetic valve revealed wear of the Delrin disk, and widening of the gap between the disk and strut, which were presumed to be the cause of transvalvular leakage. A half century has passed since introduction of the Björk-Shiley valve and the present is a rare case of valve malfunction. Presented here are related details, along with a review of existing literature and results of Björk-Shiley valve use at our hospital.