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Early Experience with the 19-mm Medtronic Mosaic Porcine Bioprosthesis for Small Aortic Annuli

Hiroshi Kagawa ; Yoshimasa Sakamoto ; Hiroshi Okuyama ; Shinichi Ishii ; Shingo Taguchi ; Kazuhiro Hashimoto

Japanese Journal of Cardiovascular Surgery.2008;37(1):1-5. doi:10.4326/jjcvs.37.1

A study was conducted to evaluate the clinical and hemodynamic performance of the 19-mm Medtronic Mosaic Valve (MMV) in the aortic position, which is a third-generation stented porcine bioprosthesis. Between 2003 and 2006, 9 patients underwent AVR using the 19-mm MMV. None of the patients were suitable for a 19-mm Perimount bioprosthetic valve due to having a small annulus and sinotubular junction. The patients included 3 men and 6 women with a mean age of 73.2±4.97 years and mean body surface area of 1.35±0.11m². Preoperatively, 8 patients were in New York Heart Association class II and 1 was in class III. The reason for surgery was aortic stenosis in 8 patients and aortic regurgitation due to infective endocarditis in 1 patient. Four patients had chronic renal failure and were on hemodialysis, while 1 patient had Crohn's disease. Concomitant coronary artery bypass grafting was performed in 3 patients, and tricuspid valve annuloplasty was done in 1 patient. The follow-up period was 12.0±7.71 months. No deaths occurred, but there was 1 cerebral infarction. Postoperatively, the peak pressure gradient decreased from 81.3±32.7 to 40.3±16.3mmHg (p<0.01). The mean pressure gradient also decreased significantly from 48.8±11.6mmHg to 23.9±9.32mmHg (p<0.01). Left ventricular end-diastolic diameter was 47.9±3.82mm preoperatively and 45.1±7.53mm postoperatively, showing no significant change. The left ventricular mass index also improved from 217.3±46.9 to 160±54.9g/m² (p<0.05). The ejection fraction was 72.0±8.93% preoperatively and 67.6±6.37% postoperatively, showing no difference. Although the postoperative indexed effective orifice area (EOAI) was 0.90±0.11cm²/m², mild patient-prosthesis mismatch (EOAI 0.77cm²/m²) was noted in 1 patient. In conclusion, the early clinical and hemodynamic performance of the 19-mm MMV in small elderly patients was acceptable.

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Surgical Strategy for Minimally Invasive Coronary Reconstruction in Chronic Hemodialysis Patients

Yoichiro Miyake ; Manabu Okabe ; Hiroyuki Miyagawa ; Shinji Kanemitsu ; Kensuke Ohue ; Sawaka Tanabe

Japanese Journal of Cardiovascular Surgery.2008;37(1):6-12. doi:10.4326/jjcvs.37.6

Long-term hemodialysis remains a major risk factor for coronary artery bypass grafting (CABG). In our institution, a surgical strategy for these high risk patients is the complete coronary revascularization with off-pump CABG (OPCAB) using an arterial graft. However in cases of advanced functional disorder, we choose hybrid strategy or reduction strategy, namely the target of surgical intervention is just the key vessel. Aggressive usage of continuous hemodiafiltration (CHDF) to control water and electrolytic balance intra- and post-operatively is an alternative. This study aimed to elucidate whether our strategy is appropriate for hemodialysis patients. We enrolled 608 consecutive patients who underwent CABG between August 1999 and December 2006. Among them, 25 (4.1%) had received regular hemodialysis. As a control group, 100 patients were selected randomly among 583 patients excluding 25 hemodialysis patients. All patients had at least one major complication, and 13 had several major complications. The number of preoperative complications in hemodialysis patients is significantly higher than that of control group. Mean patient age was 66.3±8.7 years. The mean number of diseased vessels was 2.32±0.7, and that of anastomosis per patient was 2.4±1.2. All patients completed the procedure without cardiopulmonary bypass (CPB) as a result. Complete revascularization was performed in 22 (88%). The causes of non-completion were a hybrid strategy with PCI in one patient in the early period and a reduction strategy in 2 on account of social indications. Perioperative mortality was 0%, while the major complication was extended pleural effusion in 3 patients and slowly progressive sternal osteomyelitis in one. Mid-term results showed 2 cardiac deaths. The surgical outcome was equivalent in the hemodialysis group and the control group, though each preoperative state was not equal. Our strategy for patients undergoing chronic hemodialysis attained excellent perioperative and mid-term outcomes. We consider OPCAB produced better outcomes. CHDF is an important tool for use in surgical intervention in these patients.

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Surgical Management of Perivalvular Leakage after Mitral Valve Replacement

Yoshimasa Sakamoto ; Kazuhiro Hashimoto ; Hiroshi Okuyama ; Shinichi Ishii ; Shingo Taguchi ; Takahiro Inoue ; Hiroshi Kagawa ; Kazuhiro Yamamoto ; Kiyozo Morita ; Ryuichi Nagahori

Japanese Journal of Cardiovascular Surgery.2008;37(1):13-16. doi:10.4326/jjcvs.37.13

Perivalvular leakage (PVL) is one of the serious complications of mitral valve replacement. Between 1991 and 2006, 9 patients with mitral PVL underwent reoperation. All of them had severe hemolytic anemia before surgery. The serum lactate dehydrogenase (LDH) level decreased from 2,366±780 IU/l to 599±426 IU/l after surgery. The site of PVL was accurately defined in 7 patients by echocardiography. PVL occurred around the posterior annulus in 3 patients, anterior annulus in 2, anterolateral commissure in 1, and posteromedial commissure in 1. The most frequent cause of PVL was annular calcification in 5 patients. Infection was only noted in 1 patient. In 4 patients, the prosthesis was replaced, while the leak was repaired in 5 patients. There was one operative death, due to multiple organ failure, and 4 late deaths. The cause of late death was cerebral infarction in 1 patient, subarachnoid hemorrhage in 1, sudden death in 1, and congestive heart failure (due to persistent PVL) in 1. Reoperation for PVL due to extensive annular calcification is associated with a high mortality rate and high recurrence rate, making this procedure both challenging and frustrating for surgeons.

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Rupture of the Aortic Arch and Descending Aortic Aneurysm in a 24-Year-Old Man with Systemic Lupus Erythematosus

Akihiko Sasaki ; Akira Fujii ; Masahiro Miyajima

Japanese Journal of Cardiovascular Surgery.2008;37(1):17-20. doi:10.4326/jjcvs.37.17

A 24-year-old man with systemic lupus erythematosus (SLE) had received long term steroid therapy 10 years prior to this admission. He presented with sudden-onset chest pain. Enhanced CT scan showed the presence of an aortic arch aneurysm 63mm in maximum diameter and a hematoma surrounding the anterior mediastinum. The diameter of the descending thoracic aorta was also dilated to 5cm. We performed ascending and total arch replacement on December 8, 2005. From the 11th postoperative day, he developed fever, indicating mediastinitis. Open drainage was carried out for one week resulting in gradual lysis of fever and the levels of WBC and CRP returned to normal values. The omentum was transplanted to close the defect in the mediastinum. The rest of the postoperative course was uneventful. He was discharged from the hospital last January 25, 2006. Although close medical follow-up was implemented, he had severe chest pain in the morning on June 9, 2006. Enhanced CT showed an expanding descending aortic aneurysm 60mm in diameter. Since antihypertensive therapy was effective, we considered an elective operation. On the 3rd hospital day, he complained of a severe back pain wherein he rapidly progressed into a state of shock. He died due to rupture of the descending aortic aneurysm. We needed emergency operation or endovascular stent graft therapy because of the risk of rupture.

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A Surgical Case of Infective Endocarditis Presenting with Intracranial Hemorrhage due to Ruptured Cerebral Mycotic Aneurysm

Tomoyuki Yunoki ; Kenji Minakata

Japanese Journal of Cardiovascular Surgery.2008;37(1):21-24. doi:10.4326/jjcvs.37.21

It is still controversial how to treat patients with active infective endocarditis associated with cerebral complications such as embolic stroke or intracranial hemorrhage. Cerebral mycotic aneurysm is a major risk factor for intracranial hemorrhage both preoperatively and intraoperatively. We encountered a 62-year-old man who presented with intracranial hemorrhage due to ruptured cerebral mycotic aneurysm associated with active infective endocarditis. Echocardiography demonstrated severe aortic and mitral regurgitation with vegetation and perforation of leaflets. Since he did not have significant heart failure symptoms, we performed craniotomy including removal of hematoma and exclusion of the mycotic aneurysm. Subsequently, we performed the open heart procedure for his mitral, aortic and tricuspid valves after 4 weeks from the onset of intracranial hemorrhage. His postoperative course was uneventful and he recovered completely without neurological deficits. Here, we report this case with some literature review.

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A Successful Surgical Repair for Nonpenetrating Cardiac Trauma with Concomitant Rupture of the Pericardium

Takanori Suezawa ; Mamoru Tago ; Toru Morimoto ; Teiji Jinno

Japanese Journal of Cardiovascular Surgery.2008;37(1):25-28. doi:10.4326/jjcvs.37.25

We report a case of nonpenetrating cardiac trauma successfully managed by an emergency operation. An 82-year-old woman, who was involved in a traffic accident, was transferred to our institution from a remote island in a critical condition accompanied with left hemothorax, loss of consciousness, subarachnoid hemorrhage and right humerus fracture. She was transported rapidly to the operation room, and immediate left thoracotomy revealed a small cardiac rupture on the free wall of right ventricular outflow tract with concomitant rupture of the pericardium. The wound was controlled by digital compression, and was closed with interrupted pledgeted sutures without cardiopulmonary bypass. She regained consciousness gradually although tracheotomy was needed, and was moved to another local hospital in a stable condition.

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Severe Circulatory Shock Induced with Protamine Sulfate during Cardiac Surgery in a Diabetic Patient Who Had Exposure to Neutral Protamine Hagedorn Insulin

Kiyohito Yamamoto ; Takane Hiraiwa ; Hisato Ito

Japanese Journal of Cardiovascular Surgery.2008;37(1):29-31. doi:10.4326/jjcvs.37.29

A 60-year-old woman was admitted to our hospital due to abnormal findings on an electrocardiogram. She was a diabetic patient and had been taking neutral protamine Hagedorn insulin previously. After admission, since a coronary angiography was performed and showed three-vessel disease we performed coronary artery bypass grafting. After the cardiopulmonary bypass, she was given protamine sulfate. Subsequently her systolic blood pressure decreased below 35mmHg. Immediately cardiopulmonary bypass was restarted as an assist device for circulation. We administered epinephrine, and her blood pressure increased. After the second cardiopulmonary bypass, protamine administration was not given. Her postoperative course was uneventful, and she was discharged on the 18th postoperative day. A skin test titration to protamine was done. She had positive reaction at a dilution of 1mg/ml. Neutral protamine Hagedorn insulin use may immunologically sensitize patients to protamine, leading to anaphylactic reaction upon subsequent exposure to protamine sulfate during cardiac surgery. It is important to avoid adverse reaction to protamine.

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A Successfully Operated Case of a Pseudoaneurysm-Rectal Fistula after Surgical Repair of a Ruptured Abdominal Aortic Aneurysm

Katsuo Matsuki ; Hidenori Fujiwara

Japanese Journal of Cardiovascular Surgery.2008;37(1):32-35. doi:10.4326/jjcvs.37.32

Aneurysmectomy with bifurcated graft replacement was initially performed on a patient with a ruptured abdominal aortic aneurysm, and an emergency operation was performed successfully on a proximal anastomosis pseudoaneurysm-rectal fistula that was diagnosed by bloody stool a year after operation. On the 10th postoperative month, CT detected a small pseudoaneurysm at the anastomosed prosthetic aortic graft. On the 1st postoperative year the patient first passed a slight amount of bloody stool, after which there was a large amount of bloody stool. Emergency CT and barium enema showed a pseudoaneurysm extending from near the anastomosed prosthetic aortic graft to the upper margin of the rectum and perforation into the upper rectum (Rs). An abscess covered the prosthetic aortic graft in the pseudoaneurysm, extending to the retroperitonerum on the left. We judged the case to be prosthetic aortic graft infection caused by the abscess and performed an emergency operation. The operation consisted of removal of the bifurcated prosthetic aortic graft, right axillo-bifemoral artery bypass, debridement, lavage, and packaging of the gastrocolic omentum. We report a successfully operated case of prosthetic aortic graft infection caused by pseudoaneurysm, rectal perforation and retroperitoneal abscess.

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Syncope on Exertion due to Congenital Hypoplasia of the Left Main Coronary Artery

Kazuya Kumagai ; Hajime Kin ; Kazuhiko Uwabe ; Satoshi Ohsawa ; Kotaro Oyama ; Shin Takahashi ; Yoko Sato ; Hitoshi Okabayashi

Japanese Journal of Cardiovascular Surgery.2008;37(1):36-39. doi:10.4326/jjcvs.37.36

A 13-year-old girl was admitted to our hospital with a history of syncope after exercise. Neither left ventricular (LV) function nor hypertrophy was detected by transthoracic echocardiography. However, 24-h Holter electrocardiogram demonstrated ST segment depression with increasing heartbeat. Exercise ²⁰¹Tl myocardial scintigram also demonstrated ischemia of the anterior LV wall. Multi-slice coronary computed tomography (CT) demonstrated hypoplasia of the left main coronary artery. The syncope on exertion was ascribed to myocardial ischemia due to hypoplasia of the left main coronary artery. We performed off-pump coronary artery bypass graft (CABG) (left internal thoracic artery-left descending artery). The postoperative course was uneventful and postoperative stress ²⁰¹Tl myocardial scintigram demonstrated the absence of myocardial ischemia. Coronary CT demonstrated good graft patency. To date, there has not been any recurrence of syncope on exertion. We herein report a successful off-pump CABG for a patient with syncope due to hypoplasia of the left main coronary artery. Syncope on exertion due to hypoplasia of the left main coronary artery is very rare. However, certain forms of congenital coronary anomalies are associated with adverse cardiac events, including sudden cardiac death. The diagnosis, therefore, can be important and CABG is indicated, especially when there is repetitive syncope due to myocardial ischemia.

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A Case of Left Atrial Myxoma Mimicking Mitral Valve Stenosis Which Required the Mitral Valvoplasty after Tumorectomy

Keijiro Katayama ; Masafumi Sueshiro ; Osamu Ishii ; Hironori Kobayashi

Japanese Journal of Cardiovascular Surgery.2008;37(1):40-43. doi:10.4326/jjcvs.37.40

A 58-year-old woman was referred to our department with subacute onset dyspnea on effort. A transthoracic echocardiogram revealed mobile left atrial mass originating from the intra-atrial septum, and almost obstructing the left atrial outflow in diastole. From continuous doppler recordings of the tricuspid valve, a systolic pulmonary artery pressure of 114mmHg was estimated. The tumor was exposed through a left atriotomy after bicaval cannulation for cardiopulmonary bypass (CPB). We performed complete excision of the tumor with the endocardium of the intra-atrial septum, to which it was attached. The defect was closed directly with running sutures. The CPB was weaned off uneventfully, however, there was moderate mitral regurgitation shown by transesophageal echocardiogram. Repeat cardioplegic arrest was induced and the mitral valve was exposed again, and mitral valvoplasty was performed. The mitral incompetence was probably due to an extreme tension of the mitral annulus after closure of the resulting intra-atrial defect.

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