Systolic anterior motion (SAM) is a common complication of mitral valve repair surgery and occasionally requires further treatment. A 56-year-old woman with severe mitral regurgitation accompanied by posterior leaflet prolapse underwent mitral valve plasty including hour-glass-shaped resection, chordal replacement, and interrupted commissural band annuloplasty. The mitral valve was exposed via a right-sided left atriotomy. We found a large thick P2-3 scallop (27 mm in height) with ruptured and elongated chordae. After repair, transesophageal echocardiography (TEE) revealed SAM of the anterior mitral leaflet and severe mitral regurgitation upon weaning from the cardiopulmonary bypass. Although catecholamine was discontinued and volume loading applied, the SAM did not improve. We decided to revise the mitral plasty. Therefore, although the height of the P3 scallop after resection remained 17 mm, neochordae were placed once more on the basal side of the posterior leaflet, and the leaflet was shortened by placing a continuous suture near the annulus. This reduced the height of the posterior leaflet and moved the co-aptation line posteriorly. After this repair, TEE showed that the SAM had disappeared. Thus, repositioning the neochordae and shortening the posterior leaflet by applying a continuous suture effectively and rapidly eliminated the problem.

Our strategy for active infective native mitral valve endocarditis was to perform valve plasty after stabilizing the active endocarditis with antibiotics as much as possible. From 1997 through 2007, a consecutive series of 16 patients underwent mitral valve plasty for active infective native mitral valve endocarditis at our department. The purpose of this study was to retrospectively assess the clinical results. The mean age was 54.6±13.4 years, and 69% were men. Surgical indications were uncontrolled infection. The mean time between onset and diagnosis was 51.6±68.0 days, and that between diagnosis and operation was 35.8±15.2 days. Two patients were operated in the early phase because of uncontrolled sepsis. Operative and pathological findings revealed active infection in 14 patients (87.5%). However, there were some findings healing suggesting in the vegetations. According to the underlying lesion, mitral valve lesions were classified into 4 groups: anterior leaflet prolapse (3 patients), posterior leaflet prolapse (10 patients), commissural prolapse (2 patients) and non-prolapse (1 patient). We tried to remove or slice only vegetation, and we preserved adjacent leaflet tissue as much as possible. All mitral valve were successfully repaired. There was 1 (6.3%) operative death because of cerebral hemorrhage. The mean follow-up period of the surviving 15 patients was 4.2±2.9 years. There were no late deaths, no re-operations and no recurrence of moderate to severe mitral regurgitation. We conclude that a sufficient period of pre-operative antibiotic administration improves the prognosis, and our plastic technique of limited removal of the leaflet tissue was safe and effective.

Background : Aortic valve stenosis may be complicated by atherosclerotic lesions in the ascending aorta, which may cause cerebral infarction due to intraoperative dispersion of atheromas. We describe herein a safe aortic cross-clamping technique after removal of the sclerotic lesion in the ascending aorta during short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest. Methods : From January 2006 to March 2014, a total of 144 patients underwent aortic valve replacement (AVR) for treatment of aortic valve stenosis. Patients who required ascending aorta replacement surgery, had infective endocarditis, or required emergency surgery were excluded. Five patients underwent AVR using unilateral selective cerebral perfusion and mild hypothermic circulatory arrest due to the presence of atherosclerotic plaques or severe calcification of the ascending aorta (Compromised Aorta group), and 139 patients underwent AVR using ascending aortic perfusion and clamping (Control group). Cardiopulmonary bypass using the right axillary and femoral arteries was started and cooled to a pharyngeal temperature of 34°C in the Compromised Aorta group. During hypothermic circulatory arrest, the brachiocephalic artery was clamped and unilateral selective cerebral perfusion was administered from the right axillary artery. The perfusion volume was adjusted to 500 to 800 ml while using the cerebral oxygen saturation monitor. After transection of the ascending aorta, the atheroma and suture line calcification were removed. A suitable site for cross-clamping was identified under direct vision, and the aorta was carefully cross-clamped. Results : The patients in the Compromised Aorta group required a mean circulatory arrest period of 3.8 min (range, 3.0-5.5 min). The mean minimum value of the left-side cerebral oxygen saturation was 52.0% (range, 45-58%). No patients in the Compromised Aorta group died or developed cerebral complications (95% confidence interval (CI) 0.000-0.522). Complications in the Control group included in-hospital mortality (3/140, 2.2% ; 95%CI : 0.003-0.046 ; p=0.899), stroke (2/139, 1.4% ; p=0.932), transient neurologic deficits (4/139, 2.9% ; p=0.867), and total cerebral complications (6/139, 4.3% ; 95%CI : 0.009-0.077 ; p=0.806). Additionally, there were no significant differences between the Compromised Aorta and Control groups in the operative time (345.8±71.8 vs. 333.6±85.4 min, respectively ; p=0.754), cardiopulmonary bypass time (196.4±63.6 vs. 199.2±50.0 min, respectively ; p=0.902), and aortic cross-clamp time (132.0±44.1 vs. 124.8±36.3 min, respectively ; p=0.666). Conclusion : Short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest is a safe strategy in patients undergoing AVR with a severely atherosclerotic aorta. The outcomes of this strategy were equivalent to those in the Control group, which had fewer atherosclerotic lesions in the ascending aorta.

Acute aortic dissection complicated with acute myocardial infarction in a case of 61-year-old woman with an aberrant right coronary artery was successfully treated by emergency operation fore type A acute aortic dissection. However, cardiogenic shock and bradycardia occurred after induction of anesthesia due to right ventricle myocardial ischemia. Cardiopulmonary bypass was established quickly and deep hypothermia was induced. We also perfused the right coronary artery with an external shunt tube to prevent the progression of the right ventricular infarction. The right coronary artery, which originated above the left coronary sinus, was dissected totally. We performed ascending and aortic arch replacement and coronary artery bypass grafting with a saphenous vein graft to the right coronary artery under hypothermic circulatory arrest. She had no major reduction of cardiac function. Although it was a rare combination, aberrant right coronary artery was vulnerable to myocardial ischemia associated with acute type A dissection. The external coronary shunt tube was useful for this type of myocardial ischemia.

In 2005, a 64 year-old man underwent implantation of a sirolimus-eluting stent at another hospital for the treatment of severe stenosis of the right coronary artery (RCA) that caused unstable angina pectoris affecting the inferior cardiac wall. He was subsequently admitted to our hospital because of recurrent angina. Diagnostic coronary angiography, performed in November 2006, revealed 75% stenosis of the left main trunk and 99% stenosis of the left circumflex artery. We planned to perform off-pump coronary artery bypass grafting on May 6, 2007. Ticlopidine and aspirin were discontinued 14 days and 1 day before the operation, respectively. We then started continuous intravenous heparin administration. During the operation, the right internal mammary artery was grafted to the left anterior descending artery, and after rotation of the heart in order to graft to the circumflex artery, hypotension and ST elevation in electrode II occurred. The left internal mammary artery was grafted to the left circumflex artery under the support of intra-aortic balloon pumping, but the ST elevation did not normalize. Therefore, an extracorporeal cardiopulmonary bypass was started. Despite the coronary recanalization, the ST elevation in electrode II did not recover. Because of thrombosis of the drug-eluting stent, an aorto-coronary bypass graft to the RCA was performed with a saphenous vein graft. There was no proximal blood flow at the RCA incision. Therefore, we perfused the RCA via a shunt tube from the cardiopulmonary bypass, and subsequently the ST change normalized. However, ST elevation recurred after the operation. An emergency angiography performed immediately postoperatively revealed a patent saphenous vein graft and drug-eluting stent, and spastic change in the RCA distal from drug-eluting stent. After the initiation of a continuous intravenous drip of nicorandil, hypotension and the ST change recovered. Attention to coronary artery spasm after drug-eluting stent implantation is important.

Horseshoe kidney is a common renal anomalies, but coexistence with abdominal aortic aneurysm (AAA) is rare. Horseshoe kidney may cause various technical difficulties of aneurysm repair. A 76-year-old man was referred to our hospital for treatment of AAA with a horseshoe kidney. Preoperative 3-dimensional computed tomography (3D-CT) scans showed a pair of normal renal arteries and 3 accessory renal arteries from the anterior wall to abdominal aorta just proximal to an aneurysm. At operation, the aneurysm was exposed through a transperitoneal approach, and artificial graft replacement was performed with a woven Dacron bifurcated graft preserving the renal isthmus. The accessory renal arteries were not reconstructed. The postoperative course was uneventful. Postoperative 3-D CT showed minor infarction of renal isthmus, but renal function was not impaired.