A 57-year-old male had single bypass graft to the right coronary artery with a saphenous vein graft 20 years previously. He noticed recurrent anginal pain since 1991 and thoracic aortic aneurysm was also pointed out in 1993. Coronary angiography showed that the saphenous vein graft was occlusion, accompanied with the distal portion of the occluded anterior descending coronary artery perfused by collateral flow from the circumflexus branch. The left ventricular function was moderately impaired (EF=38%). Re-do of coronary artery bypass grafting was done to the AV branch of the right coronary artery with the right gastroepiploic artery and the primary sequential grafting to anterior descending coronary artery and diagonal branch with left internal thoracic artery. One month after CABG, graft replacement of descending thoracic aorta was done because of thoracic aortic aneurysm. The postoperative course was uneventful except for the complication of chylothorax after the second operation. Postoperative angiography showed good patency of the left internal thoracic artery and right gastroepiploic artery and no abnormality of the graft anastomosis.

A 61-year-old male had received aortic valve replacement due to AR in 1987 and the operative findings showed the enlargement of the ascending aorta and maximum diameters of 4cm in the ascending aorta. He had been doing well until 1992 when he sufferred cerebral infarction and aortic root dilatation reached a maximum diameter of 7.5cm demonstrated by CT. Cabrol's operation using the previously replaced aortic valve was carried out because the prosthetic valvular function was normal and the type of coronary arteries was balanced. Postoperative angiography showed good patency at anastomosis of bilateral coronary arterial orifices and he had a satisfactory postoperative course. The dilatation of the ascending aorta over 4cm accompanied with AR may need not only AVR but also aortic root replacement.

A 64-year-old woman with a diagnosis of calcified aortic valvular stenosis and unstable angina, had calcification of the aortic valve reaching the aortic annulus, and the ascending aorta had some calcifications in its lateral and posterior walls. There was a 70mmHg pressure gradient in the aortic valve and coronary angiogram showed 90% stenosis of right coronary artery #1 and total occlusion of left circumflex artery #13 perfused with collateral flow from right coronary artery. The translocation of the aortic valve was carried out. The postoperative course was uneventful and postoperative angiograms showed good patency of the double saphenous vein grafts and no abnormality of the composite graft anastomosis. Translocation of the aortic valve is effective in patients with stenotic aortic annulus caused by calcified aortic valve, although it is mainly indicated in infective endocarditis.

[Background] Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM) in Europe and America. However, few cases underwent surgical septal myectomy in Japan. We have performed the surgical transaortic extended left ventricular myectomy (LV myectomy) as a first choice in HOCM patients unresponsive to pharmacologic therapy. We report the short and medium term clinical outcomes. Methods : From May 2012 to September 2014, 9 patients underwent extended LV myectomy without other accompanying procedures. All cases were symptomatic and peak left ventricular outflow tract pressure gradients (LVOTG) were 50 mmHg or more. We assessed clinical and echocardiographic outcomes at the short and medium term, intra-operative findings and cardiomyocyte pathological findings. Results : All patients (mean age 64.3 years, 56% female) underwent transaortic LV myectomy with no obvious complications. Postoperative LVOTG were controlled within 10 mmHg or less. SAM disappeared completely in all patients and MR decreased to mild or less. LVOTG sustained good control of 10 mmHg or less under low-dose dobutamine stress echocardiography at the medium term. Conclusion : Our transaortic extended LV myectomy procedure is effective in decreasing LVOTG, SAM and MR with low operative morbidity and mortality.

A new technique of left atrial plication (LAP) for giant left atrium (GLA) resulting from mitral regurgitation (MR) is reported. A 66-year-old man was found to have NYHA class III resulting from severe MR, mild TR and GLA with a left atrial diameter (LAD) of 107mm on echocardiogram. Chest X-ray showed the cardiothoracic ratio (CTR) to be 92%, and the right side CTR was 88.4%. Surgery was performed under general anesthesia with endotracheal intubation. Under cardiac arrest established by antegrade and retrograde cardioplegia, mitral repair was performed first through a superior transseptal approach. Left atrial resection was continued paralell to the mitral posterior annulus and to the right side wall of the left atrium, following the right side resection. Simultaneously the left atrial wall was incised 3 to 4cm in width all the way along the resection line and it was closed by a running suture of 3-0 prolene. The continuous line of the left atrial plication formed a spiral shape. A prominent portion of the atrial septum resulted from the LAP and the right atrial wall was also resected and plicated. The postoperative course was uneventful, and the postoperative CTR reduced to 71% with a right side CTR of 54.4% with reduction of LAD to 67mm on ultrasound cardiogram (UCG). This spiral LAP was considered more effective to reduce all dimensions of the giant left atrium dilated in all directions in comparison with other LAP methods previously reported.

No abstract available.
Aorta, Thoracic ; Transcatheter Aortic Valve Replacement