Search

We experienced a case of infective endocarditis caused by Abiotrophia defectiva in which aortic, mitral, and tricuspid valve surgery was performed. Even if blood cultures are negative, it is important to treat patients with endocarditis considering the possibility that some organisms are difficult to detect via conventional blood culture. Embolism is a complication that should not be overlooked in cases of infective endocarditis, particularly those caused by Abiotrophia defectiva, which tends to cause embolism. As the patient had splenic and cerebral infarction preoperatively, early surgical intervention was performed to prevent further embolisms, and the patient's postoperative course was excellent.

A 30-year-old woman with a more than 6-month history of fever, weight loss, general fatigue and dysesthesia of lower extremities was admitted to our hospital with a diagnosis of infective endocarditis. Blood cultures revealed Staphylococcus oralis. Echocardiography revealed severe mitral and moderate tricuspid regurgitation, as well as massive vegetations and aneurysms on the mitral valve. Computed tomography revealed an abdominal aortic aneurysm, left common and external iliac arterial aneurysms, and occlusion of the left common iliac, the deep femoral arteries and the bilateral tibioperoneal trunk. The ankle brachial pressure indices (ABI) were 0.94 (right) and 0.61 (left). She initially underwent mitral valve replacement and tricuspid annuloplasty. On postoperative day 24, the affected segments of the arteries were replaced with a woven Dacron bifurcated graft after resection of the mycotic abdominal and the iliac arterial aneurysms. We could not obtain a sufficient amount of omental pedicle to wrap the prosthesis. Her postoperative course was uneventful and mycotic arterial embolism and aneurysm did not recur.

A 64-year-old man was admitted to our hospital with chief complaint of chest discomfort. He received coronary artery bypass grafting utilizing the in situ left internal thoracic artery 10 years ago. Coronary and left subclavian artery angiogram revealed coronary subclavian steal syndrome and 90% stenosis in the proximal left subclavin artery. Ultrasonography of neck vessels demonstrated 75% stenosis in the bifurcation of left carotid artery. We performed axilloaxillary artery bypass grafting to avoid brain ischemia. Myocardial thallium scintigraphy on dipyridamole testing after axilloaxillary artery bypass grafting could not detect myocardial ischemia. Axilloaxillary artery bypass grafting was effective for coronary subclavian steal syndrome.

A 50-year-old woman was admitted to our hospital because of heart failure (NYHA III) due to mitral valve regurgitation (MR) with pulmonary hypertension (PH) and tricuspid valve regurgitation (TR). She had a history of chronic renal failure undergoing dialysis (peritoneal dialysis, homodialysis) since 1996. Cardiac catheterization and ultrasonic cardiography showed severe MR (Sellers III), severe TR and PH (mean pressure 33 mmHg). So we performed mitral valve replacement and tricuspid annuloplasty (DeVega). Frequent blood transfusion was needed because severe hemolytic anemia appeared after operation. Ultrasonic cardiography demonstrated moderate aortic valve regurgitation (AR) with no paravalvular prosthetic leakage. We diagnosed hemolytic anemia due to AR. We performed aortic valve replacement. Hemolytic anemia improved soon after second operation. We investigated the mechanical process of the AR. She had a very short subaortic curtain (5.9 mm) compared with the average (8.7 +/- 2.1 mm: mean +/- SD) of cardiac patients. We think that we must be very careful with suture to short subaortic curtain. In addition measurement of subaortic curtain before operation is very useful.

We have developed a blood cardioplegia delivery system for children. Essential points of a delivery system in pediatric cardiac surgery are (1) a small amount of priming volume of a delivery system, and (2) slow, steady infusion of a cardioplegic solution. We changed a heat exchanger to a smaller one for reduction of priming volume, and changed a roller pump tube to a smaller one for slow, steady infusion. Thus, priming volume of a delivery system has reduced from 180 to 100 ml, and we can infuse a cardioplegic solution at a steady rate less than 10 ml/min. Our clinical experience with this system suggests that this blood cardioplegia delivery system is useful for pediatric cardiac surgery.

The case of a 44-year-old man with metastatic tumor of the small intestine from large cell carcinoma of the lung was reported. The patient underwent exploratory thoracotomy because of tumor invasion into the left ventricle. He was discharged from our department after chemotherapy and irradiation. However, he was again admitted because of the development of anemia secondary to melena. An abdominal ultrasonography revealed ascites and tumor of the small intestine. Symptoms of ileus also developed. A laparotomy was performed. The metastatic tumors were found in the jejunum, and resection of jejunum was performed. The postoperative course of the patient was uneventful, and he survived one month after laparotomy. Small bowel metastasis of lung cancer, which is unusual pattern of metastasis, is also reviewed.

The surgical correction was performed successfully in a 3-year-old girl with tetralogy of Fallot associated with total anomalous pulmonary venous drainage (type Ia). The preoperative cardiac catheterization and angiography showed high systolic pulmonary artery pressure (58 mmHg) and small left ventricular volume (54% of normal). The early postoperative course was stormy because of the unstable circulatory state. During the early postoperative period, we estimated the volume of left ventricle by 2 D echocardiography. A significant increase of the volume was observed on the 8th postoperative day, when her circulatory state became stable. The cardiac catheterization before discharge revealed Pp/Ps of 0.38 and normal LV volume. We conclude that primary repair should be done for this combined cardiac anomaly, even if small left ventricle and pulmonary hypertension is present.

A case of a 66-year-old man with ischemic heart disease and lung cancer is reported. Chest roentgenogram revealed an irregular 2.8 x 2.0 cm mass in the right upper lobe. Coronary angiography showed 75-90% stenosis of the left anterior descending artery, and these lesions was suspected to cause perioperative myocardial infarction. A concomitant operation of aorto-coronary bypass graft and right upper lobectomy was performed through median sternotomy. A concomitant operation must be considered to be definitive and ideally preferable in selected cases.

We treated 15 children with atrioventricular septal defects (6 complete type and 9 incomplete type) using total circulatory annuloplasty for mitral regurgitation. In 14 patients, total circulatory annuloplasty was performed with absorbable suture and in one patient with polypropylene suture. Operative death was one patient associated with tetralogy of Fallot and another 14 patients survived. Preoperative mitral regurgitation was grade 1 in one patient, grade 2 in 6 patients and grade 3 in 7 patients. After operation mitral regurgitation reduced to grade 1 in 13 patients and grade 2 in one patient. In the late results, only one patient underwent reoperation for exacerbation of mitral regurgitation. The present data suggested that total circulatory annuloplasty with absorbable suture was very useful technique for the repair of mitral regurgitation of atrioventricular septal defects in children.

Two rare cases with surgically treated vascular ring associated with complex congenital cardiac anomaly are reported. Each case showed vascular ring due to right aortic arch, right descending aorta, aberrant left subclavian artery and left ductus arteriosus. Case 1 was a 2-year-old boy associated with ligamentum arteriosum and total anomalous pulmonary venous connection (TAPVC), and presented dyspnea and dysphagia. Case 2 was a 3-year-old girl associated with patent ductus arteriosus (PDA) and tetralogy of Fallot (TOF). In case 1, the two-staged operation was performed because of the necessity of mechanical ventilation and of recurrent respiratory infection. Division of the ligamentum, dissection of bronchus and esophagus was performed at the first operation through left thoracotomy, and the intracardiac repair of TAPVC was done three months later. In case 2, PDA division and the intracardiac repair of TOF was done simultaneously through median sternotomy because of the mild symptom of vascular ring and technical feasibility. Each case was successfully treated and became completely asymptomatic.

From 1965 to 1990, 49 valve replacements were performed on 43 patients under the age of 15. Mitral valve replacements were performed on 21 patients, and re-replacements were done on 4 of them afterwards. In the first 9 mitral valve replacements before 1974, Starr-Edwards (S-E) ball valves were used. Five of these patients died in the hospital (early mortality rate was 56%). Since 1975, bioprosthetic valves were used in three cases, but all of these valves ceased to function due to primary tissue failure (PTF) within 3 years. Consequently, SJM valves are now used as a first choice. Ten aortic valve replacements were performed on 9 patients with the results of one early death, two late deaths, and one late re-operation. Tricuspid valve replacements were performed on 11 patients, 5 of whom utilized S-E ball valves. Three of the five patients died in the hospital. One patient was re-operated on, swapping the S-E ball valve for the SJM valve. SJM valves were used primarily in 2 patients, and bioprosthetic valves in 4. Two patients died, one with a SJM valve, and the other with a bioprosthetic valve. Two pulmonary valve replacements were performed, one employing a SJM valve, the other a bioprosthetic valve. Two adult patients with SJM valve in the right side of the heart had thrombotic complications, though the patients with bioprosthetic valves had none. Atrioventricular valve replacements were performed on 5 patients under the age of 3, but all of them died.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1985 to 1989, 4 neonates or infants (3 males and 1 female) underwent open valvotomy for severe aortic valve stenosis. In all patients, preoperative echocardiograms showed abnormal findings of endocardial fibroelastosis and/or poor performance of left ventricle. All patients underwent valvotomy using cardiopulmonary bypass. There was one early death from left ventricular failure. All other patients survived and the pressure gradient through aortic valve was reduced from 50-100 mmHg to 25-50 mmHg postoperatively. We conclude that infants with severe aortic valve stenosis should undergo open valvotomy before the manifestation of endocardial fibroelastosis and/or left ventricular muscle damage, and that open aortic valvotomy using cardiopulmonary bypass is most suitable method for severe aortic valve stenosis in infants.