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An 8-year-old boy had undergone permanent epicardial pacemaker implantation with a Y-shaped bipolar ventricular lead on day 6 after birth for treatment of congenital complete atrioventricular block. He was found to have pulmonary stenosis and mitral stenosis by follow-up echocardiography. Further studies including computed tomography and cardiac catheterization revealed that the pacemaker lead had completely encircled the cardiac silhouette and was in a state of “cardiac strangulation”. We removed the previous pacing leads and generator and implanted a new epicardial dual-chamber pacing system in the right atrium and right ventricle. Additionally, an expanded polytetrafluoroethylene sheet was placed between the new leads and the heart to prevent recurrence of cardiac strangulation.

Mycotic aortic aneurysm (MAA) is rare but lethal. Detection of the causative bacteria is important for successful treatment. In some cases, however, no micro-organisms are detected by repeated blood cultures. Open surgery is the standard procedure for MAA, but endovascular intervention is also performed. An aneurysm specimen cannot be taken for culture when using an endovascular approach, decreasing the opportunity to detect the causative organism. We performed successful endovascular repair in a rare case of a Peptostreptococcus micros-induced MAA as detected by postoperative computed tomography-guided biopsy. This case may help to establish appropriate medical treatment for MAAs. Keywords: Mycotic aneurysm, Endovascular, Stent graft, Peptostreptococcus micros, Computed tomography-guided biopsy

Progressive dilatation of the pulmonary autograft is one of the greatest concerns after the Ross procedure. Increased stress in the arterial wall may cause changes in the elastic properties of the pulmonary autograft, and thus lead to pathological dilatation. The present study aimed to investigate the changes in the autograft diameter and stiffness during follow-up after the Ross procedure. A total of ten patients underwent the Ross procedure at our institution between 2003 and 2011. Echocardiography was used to measure the diameters of the pulmonary autograft at the level of the annulus, sinus of Valsalva, and sinotubular junction. The stiffness index was calculated from the angiographic data, and compared with that of 16 age-matched control children. The diameters of the pulmonary autograft increased throughout the follow-up period, particularly at the level of the sinus of Valsalva and at the sinotubular junction. The aortic root was stiffer in Ross patients compared with control children (7.9 ± 1.8 vs. 3.9 ± 0.7 immediately postoperatively, p

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA)-related disease that manifests as a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI) and is caused by uncontrolled activation of the complement system. We report the case of a 61-year-old woman with acute type A aortic dissection that subsequently developed into aHUS. The hematologic disorders underlying aHUS improved after treatment with the complement inhibitor eculizumab. It is important to consider aHUS when a patient clinically develops a triad of microangiopathic hemolytic anemia, thrombocytopenia, and an increasing creatinine level following cardiovascular surgery.

Axillary artery aneurysms are uncommon and potentially high-risk lesions threatening the upper extremities. In hemodialysis patients, arteriovenous fistulae creation rarely triggers aneurysmal degeneration and arterial aneurysms in inflow arteries. These aneurysms are usually treated by surgical repair. However, this may lead to complications because of the anatomical complexity surrounding aneurysms of axillary arteries. We report a patient undergoing hemodialysis who had a ruptured ipsilateral axillary artery aneurysm proximal to vascular access. We successfully treated it by endovascular repair with the GORE Excluder AAA contralateral leg endoprosthesis, approaching from the left brachial artery proximal to the shunt. No complications occurred during 15 months after the endovascular repair.

Translocation mitral valve replacement by anchoring to the left atrial wall instead of the mitral annulus is sometimes performed, but the fragility of the atrial wall is a concern. We report on a patient who suffered a left atrial laceration leading to left ventricular rupture after translocation mitral valve replacement. A surge of hypertension may have predisposed the patient to the laceration of the fragile left atrial wall followed by a ventricular rupture and compromised hemodynamic state.

Background: Theoretically, a multiple perfusion approach, reducing detachment of atheromatous debris from the aortic intima and its flow into the cerebral circulation, should contribute to lessen a stroke, and may be applied to complex cardiac surgery with extensive aortic disease. The aim of the present study was to examine the value of bilateral axillary artery perfusion during thoracic aortic and cardiac surgery, and to evaluate the clinical results with a particular focus on cerebral damage. Methods: From March 2002 through December 2007, 24 patients (16 male and eight female; age range, 43 to 84 years) underwent bilateral axillary artery perfusion through side grafts during cardiopulmonary bypass. Aortic surgery, including total arch replacement, hemiarch replacement, and ascending aortic replacement, was performed in 21 patients. Bilateral axillary artery perfusion was also used in three complicated valve surgeries after expanding its indication to cardiac pathology with a diseased aorta, two redo cases with severe atherosclerotic vascular disease, and one case with a porcelain aorta. Results: Bilateral axillary artery perfusion was successful in all patients. There were no complications related to this procedure except in one patient, who suffered from a local fluid retention in one wound, requiring puncture drainage. There was no hospital mortality. No strokes were identified by either clinical assessments or diagnostic imaging. Conclusions: Bilateral axillary artery perfusion is a useful method for protection of the brain during either thoracic aortic or cardiac surgery when the patients have an extensively diseased aorta. (J Card Surg 2010;25:139-142)

An 85-year-old woman with chronic kidney disease was referred to us for the examination of a tumour in the left ventricle that was not observed 2 years earlier. She was afebrile associated with negative blood cultures. Transthoracic and transoesophageal echocardiography revealed mitral annular calcification (MAC) and a highly mobile, hyperechoic, and spindle-shaped tumour …

Aortic valve surgery carries increased risks in patients with an extensively calcified aorta. We describe a technique in which we maintain systemic perfusion via bilateral axillary artery perfusion in conjunction with endoaortic balloon occlusion, and limit the circulatory arrest time. (J Card Surg 2012;27:689-691)

Development of atrial fibrillation is one of the primary indicators of cor triatriatum in adults. Here we describe a case of a patient suffering cor triatriatum coexistent with frequent paroxysmal atrial fibrillation. Paroxysms of arrhythmia were not encountered after surgical correction. Resection of an anomalous membranous septum may have contributed to interrupting the development of ectopic beats, eliminating paroxysmal atrial fibrillation.

The conductance catheter is widely used for the continuous measurement of the left ventricular (LV) pressure - volume loops. Cyclical change of the right ventricular (RV) volume may alter the parallel conductance volume, thereby affecting the LV mechanical parameters. Using 8 open-chest adult mongrel dogs, multiple LV pressure - volume loops were obtained by 2 methods: first with a vena cava occlusion (VCO) method, which involved RV volume alteration, and second with a right-heart-bypass (RHB) preparation, which decompressed the right ventricle completely. The slope of the end-systolic pressure - volume relation (Ees), the end-systolic volume associated with the end-systolic pressure of 100 mmHg (V100,es), stiffness constant (β), and the end-diastolic volume associated with the end-diastolic pressure of 9 mmHg (V9,ed) were calculated from each loop. There was minimal influence from RV volume alteration on systolic-phase indices [Ees (VCO method, 6.37±1.91 mmHg/ml; RHB preparation, 6.60±1.66 mmHg/ml; p=0.356), and V100,es (VCO method, 18.4±9.3 ml; RHB preparation, 17.8±9.0 ml; p=0.681)], but there was a significant influence on diastolic-phase indices [β (VCO method, 0.0599±0.0152; RHB preparation, 0.0839±0.0150; p=0.007), and V9,ed (VCO method, 35.6±11.3 ml; RHB preparation, 31.9±12.3 ml; p=0.001)]. The increase in the RV volume in the diastolic phase increased the parallel conductance volume, causing overestimation of the LV diastolic volume measured by the conductance catheter. (Jpn Circ J 2001; 65: 749 - 752)

An "electrical storm" is a life-threatening condition defined as a recurrent attack of ventricular tachycardia or fibrillation. The current report is a case study of a patient who had electrical storms developing unexpectedly after undergoing coronary artery bypass grafting. The electrical storms were terminated dramatically by the administration of nifekalant hydrochloride. We suggest that nifekalant hydrochloride has great therapeutic potential for the suppression of intractable ventricular tachyarrhythmias refractory to amiodarone.

Proximal extension of acute type A aortic dissection can affect the aortic valve but seldom affects the tricuspid valve. We report the case of an octogenarian who underwent successful surgical repair of an aortic dissection that was accompanied by tricuspid regurgitation. We believe that the tricuspid regurgitation was attributable to displacement of the valve resulting from aortic dissection.

Background: The lazaroid U74500A is a 21-aminosteroid that inhibits lipid peroxidation and attenuates ischemia-reperfusion injury. We examined the effect of U74500A on heart preservation with the use of a clinically relevant canine orthotopic heart transplantation model. Methods and results: Six donor dogs (group L) were pretreated intravenously with U74500A (10 mg/kg), and the dogs without pretreatment served as a control (group C, n = 6). The donor heart was preserved in cold University of Wisconsin solution for 24 hours. The heart was then transplanted orthotopically. Myocardial biopsy was performed to measure the adenosine triphosphate level at the end of ischemia. Before reperfusion, recipients in group L received another dose of U74500A (10 mg/kg) intravenously. After 3 hours of reperfusion, left ventricular function was evaluated by left ventricular pressure-volume relations with the use of a Millar catheter and conductance catheter, thereby deriving the slope of the end-systolic pressure-volume relation, the slope of the stroke work–end-diastolic volume relation, and the slope of the maximum dP/dt–end-diastolic volume relation. At the same time, serum creatine kinase MB isoenzyme and lipid peroxide levels were measured. The slopes of the end-systolic pressure-volume relation, the stroke work–end-diastolic volume relation, and the maximum dP/dt–end-diastolic volume relation for group L were significantly higher than those for group C. The adenosine triphosphate levels for group L were significantly higher than those for group C. Serum creatine kinase MB isoenzyme and lipid peroxide levels for group L were significantly lower than those for group C. Conclusions: Inhibition of lipid peroxidation by the administration of U74500A was effective for 24-hour canine cardiac preservation. These results indicate that U74500A is a promising agent for heart allograft preservation. (J THORAC CARDIOVASC SURG 1996;112:1017-26)

Spontaneous ductal aneurysm is rare in adults, although it is diagnosed sporadically, even in the elderly. Commonly, patients with a ductal aneurysm undergo an aneurysmectomy followed by patch-plasty through a lateral thoracotomy. However in older patients, more extensive surgery is often required due to more developed atherosclerotic lesions, requiring total arch replacement. Here, we describe the repair of a ductal aneurysm through a hemi-clamshell incision in an elderly patient. This method enabled excellent exposure of the entire aneurysm and, most importantly, adaptability in performing either an aneurysmectomy followed by patch closure, or total aortic arch replacement, dependent on the extent of the atherosclerotic disease once surgically exposed.

To evaluate the effect of tranexamic acid (TA) on blood loss after cardiopulmonary bypass (CPB), 157 patients who underwent elective valve replacement operations were studied, with one group of 90 patients receiving tranexamic acid (Group TA) and 67 patients serving as the control group (Group N). In group TA, 50 mg/kg of tranexamic acid was administered just before and after CPB, and every 90 minutes during CPB. The activated coagulation time was maintained at more than 450 seconds during CPB in both groups. There was no significant difference in the CPB time between the groups (163 +/- 32 min in group N and 152 +/- 38 min in group TA:NS). The time required for hemostasis was shortened in group TA, which resulted in a shorter operation time (6.7 +/- 1.5 hrs vs 6.0 +/- 1.5 hrs in group N and group TA, respectively: p = 0.006). The amount of chest tube drainage within 12 hours after surgery was significantly reduced (225 +/- 129 ml vs. 180 +/- 118 ml in group N and group TA, respectively: p = 0.026). The chest tube was able to be removed earlier in group TA, and the total blood loss was significantly smaller in group TA (402 +/- 292 ml) than in group N (631 +/- 609 ml; p = 0.004). The authors thus conclude that antifibrinolytic therapy during CPB with tranexamic acid reduces postoperative blood loss, and shortens the operation time due to an improvement in hemostasis.

From February 1975 to August 1981, 23 consecutive patients underwent tricuspid valve replacement, which was either isolated (six patients) or combined with the replacement of other valves (17) by means of a standard, glutaraldehyde-preserved Hancock porcine bioprostheses. Patients’ ages ranged from 9 to 53 (mean 36.2) years. The follow-up period ranged from 0.2 to 16.5 years (mean 9.1) and was complete in 100 % of all cases. Structural valve failure of the tricuspid Hancock valve was noticed in two patients, a 9-year-old boy and a 13-year-old girl 3.4 and 16.5 years after implantation, respectively. The actuarial freedom rate from structural valve failure at 10 years was 94 ± 6 %. There were six tricuspid prosthesis-related events: structural valve failure in two and valve thrombosis, anticoagulant-related bleeding, prosthetic valve endocarditis, and periprosthetic leak in one each, respectively. The actuarial freedom from these events at 10 years was 78 ± 10%. Five pairs of aortic/mitral-tricuspid Hancock valves were explanted simultaneously from the same patients after 8.1 to 13.9 (mean 11.4) years postoperatively. A gross examination showed no valve dysfunction in the explants from the tricuspid position, but degenerative changes with valve dysfunction in those from the mitral and aortic position were observed (none of five versus five of seven; p

大動脈弁と僧帽弁の二弁置換症例を対象に, 心筋保護液の順行性投与 (Ante) 法と逆行性投与 (Retro) 法の心筋保護効果を比較した. Ante 群15例, Retro 群 (Ante 法併用 Retro 法) 13例について, 術前および術中因子, 再灌流後CPK-MB値の推移, 術周期心筋梗塞の頻度, 術後血行動態を検討した. 術前因子は両群間に差を認めなかった. 大動脈遮断中の心筋保護液投与の間隔は Ante 群29.2±4.8分, Retro 群24.0±3.8分と Retro 群にて有意に (p

A 26 day old neonate with Type B interrupted aortic arch, a ventricular septal defect and severe subaortic stenosis underwent a successful modified Van Praagh's operation, consisting of insertion of a graft between the main pulmonary artery and descending aorta, ligation of the patent ductus arteriosus and main pulmonary artery banding distal to the graft. This palliative procedure was effective and easily performed without the aid of cardiopulmonary bypass even in this severely ill neonate with such a complex defect.

We report a case of aortic stenosis with a brain tumor in a 67-year-old man. Although he showed no clinical neurological abnormality, a computed tomography scan revealed a brain tumor. We performed aortic valve replacement under several management techniques to avoid cerebral injury. Two biochemical markers for brain injury, S-100beta and neuron-specific enolase, were measured perioperatively. The postoperative course was uneventful without neurological complication, and the biochemical markers were within the control ranges.

We report on a 76-year-old man suffering from cerebral palsy who underwent coronary artery bypass grafting. Limitation of available bypass grafts and the approach of intra-aortic balloon pump insertion are of great concern because of his specific posture resulting from multiple articular contractures. We describe our planning to survive coronary surgery in this specific situation.

Bilateral axillary arterial cannulation for selective cerebral perfusion might minimize cerebral embolic complications during surgery on the ascending aorta and aortic arch. From March 2002 through February 2004, bilateral axillary arterial perfusion was applied in 12 consecutive patients (mean age, 61.3 years). Operative procedures were total arch replacement in 8 patients, hemiarch replacement in 1, and ascending aorta replacement in 3. Antegrade selective cerebral perfusion was established through vascular grafts anastomosed to the bilateral axillary arteries and a perfusion catheter placed directly into the left carotid artery. Bilateral axillary arterial perfusion through the grafts was successful in all patients. There were no early or late deaths and no incidence of neurologic deficit. There were no complications related to cannulation of the axillary arteries. Bleeding, temporary renal failure, acute respiratory distress syndrome, and graft infection occurred in one patient each; all recovered from these complications. Bilateral axillary arterial perfusion is feasible and effective for brain protection during surgery on the ascending aorta and aortic arch.

Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) continues to pose a major threat to the lung and cardiovascular surgery patients. We propose evidence-based infection control (EBIC) against MRSA.Methods: We conducted a basic study comparing genotyping to cluster analysis using minimal inhibition concentration on 17 drugs for 21 MRSA strains. With or without EBIC using cluster analysis and global evidence, we compared the incidence of postoperative MRSA infection. Notably, we eliminated tweezers stands and emesis basins.Results: Cluster analysis showed a typing sensitivity of 72%. The use of EBIC decreased MRSA cross-infection in the recovery room. A lung surgery series showed an MRSA incidence of 1/190 before and 0/200 after EBIC was introduced. For a cardiovascular surgery series, the MRSA incidence was 2/169 before and 0/84 after EBIC was introduced. Across wards, MRSA among Staphylococcus aureus in patient fell from 68% in 1999 to 57% in 2000.Conclusions: EBIC consisting of global guidelines and cluster analysis was useful in controlling MRSA in lung and cardiovascular surgery patients.

The effects of arresting donor hearts with University of Wisconsin solution was investigated. Donor dogs were divided into two groups according to the technique used for arresting the heart. In group I (n = 6) the heart was arrested with University of Wisconsin solution, whereas in group II (n = 6) extracellular-type cardioplegia (K+ = 20 mmol/liter) was used to induce cardioplegic arrest. Aortic root pressure was measured during the infusion of solution at constant flow. In both groups, the hearts were then flushed and stored in cold University of Wisconsin solution for 6 h. The hearts were transplanted orthotopically and disconnected from cardiopulmonary bypass. Left ventricular function was evaluated by pressure-volume relations using a conductance catheter. Peak aortic root pressure during the infusion was significantly higher in group I than in group II, although post-transplant left ventricular function was similar in both groups. Although there was no difference in cardiac function after implantation, donor hearts should be arrested by extracellular-type cardioplegia to prevent coronary vasoconstriction associated with preservation in University of Wisconsin solution.

Patients with a left atrial thrombus are considered at high risk of thromboembolism. Surgical treatment is generally recommended. We experienced a case of a patient with a history of cerebral embolism related to chronic atrial fibrillation in whom, unexpectedly, no thrombi were found at thrombectomy. Although echocardiography is a useful method for detection of a thrombus in the left atrium, the possibility of a reverberation artifact should be routinely explored.

Cerebral swelling after cardiopulmonary bypass might trigger a critical cerebral consequence resulting from intracranial space-occupying lesion. We experienced a 75-year-old woman who suffered from a delayed left hemiplegia after mitral valve replacement. Urgent diagnostic imaging revealed the presence of a brain tumor with perifocal cerebral edema. Fluid shifts occurring within a few days after the cardiopulmonary bypass, manifesting the focal cerebral edema, played a key role in this unique clinical course.

To examine the correlation between the size of left atrial myxoma, the degree of pulmonary hypertension and the patient's New York Heart Association (NYHA) functional class, the records of 29 surgically treated patients with left atrial myxoma were reviewed. Of 29 patients, 23 were catheterized before surgery. As the preoperative NYHA functional class advanced, the preoperative mean pulmonary artery pressure (mmHg) was seen to increase. Moreover, the weight of the excised myxoma also correlated well with the preoperative pulmonary artery pressure value. In five patients inserted with a Swan-Ganz catheter, the mean pulmonary artery pressure decreased immediately after tumour excision. Postoperatively, the average NYHA class of the 29 patients significantly improved. These results confirmed the positive correlation between the size of the tumour, the pulmonary artery pressure, and NYHA class in patients with left atrial myxoma.

We describe two cases of coronary artery spasm that occurred during open heart operations and were treated by coronary artery bypass grafting. Vasodilators and calcium antagonists were infused directly into the right coronary artery via the side branch of the saphenous vein graft. Both patients were weaned successfully from cardiopulmonary bypass.

Between June 1984 and September 1987, 48 patients underwent Lecompte's modification of the arterial switch operation for transposition of the great arteries, including transposition with intact ventricular septum with preparatory pulmonary artery banding (n = 18), with patent ductus arteriosus (n = 11), with dynamic left ventricular outflow tract obstruction (n = 4), and transposition with ventricular septal defect (n = 15). Ages ranged from 12 days to 36 months (mean 8 months) and weights ranged from 2.7 to 12.8 kg (mean 5.7 kg). Two deaths occurred, yielding an operative mortality rate of 4.2%. Preparatory pulmonary artery banding resulted in an increase to 65 +/- 5 mm Hg in the left ventricular afterload. Linear regression of the optimum circumference of the band (Y, millimeters) against left ventricular end-diastolic volume (X, milliliters) yielded the following formula: Y = 0.23X + 19.7 (r = 0.885, p less than 0.001). Influence of left ventricular mass on cardiac function after anatomic correction was evaluated. The total amount of dopamine used after repair in patients in whom the left ventricular mass was less than 60% of normal was significantly larger than that in patients with a left ventricular mass greater than or equal to 60% of normal (p less than 0.002). The left ventricular end-diastolic volume in patients with a left ventricular mass less than 60% of normal increased significantly 2 months after operation (p less than 0.05), whereas it decreased in patients with a left ventricular mass greater than 60% of normal (p less than 0.01). We believe it is safe to perform this procedure in patients in whom the left ventricular mass is larger than 60% of normal. Most newborn infants with simple transposition can undergo correction between 10 and 20 days of life if the ductus arteriosus is kept patent with prostaglandin E1 and the left ventricle is thereby loaded. Preparatory pulmonary artery banding, when necessary, will be satisfactory if the left ventricular pressure is greater than 65 mm Hg and/or the left ventricular/right ventricular pressure ratio is greater than 0.8.

Objectives: Few data have been available regarding the immediate response in ventricular mechanics to acute volume reduction caused by aortic valve replacement for aortic regurgitation. Methods: We studied 9 patients in the operating room immediately before and after the institution of cardiopulmonary bypass. Left ventricular pressure and cross-sectional area (a surrogate of left ventricular volume) were measured with a catheter-tip manometer and a transesophageal echocardiographic system equipped with automated border-detection technology. Left ventricular pressure-area loops were constructed, and the caval occlusion method was used to obtain the slope of the end-systolic pressure-area relationship and the end-systolic area associated with 100 mm Hg. From the steady-state beats, stroke area was obtained by subtracting the minimum area from the maximum area. Effective arterial elastance, a measure of ventricular afterload, was calculated from end-systolic pressure, and stroke area as follows: effective arterial elastance equals end-systolic pressure divided by stroke area. Results: Reductions in maximum area (21.0 ± 8.5 to 16.0 ± 6.8 cm 2 [SD])and minimum area (15.3 ± 8.4 to 12.0 ± 6.1 m 2 ) shifted the baseline pressure-area loops to the left. The slope of the end-systolic pressure-area relationship (11.6 ± 4.8 to 16.0 ± 7.5 mm Hg/cm 2 ) and afterload (effective arterial elastance, 17.9 ± 11.6 to 26.3 ± 16.4 mm Hg/cm 2 ) were increased, and the end-systolic area associated with 100 mm Hg was reduced (18.3 ± 10.0 to 13.7 ± 5.8 cm 2 ). Conclusion: Correction of volume overload reduced preload (minimum area), shifted the end-systolic pressure-area relationship to the left (decreased end-systolic area), and improved ventricular contractility (increased slope of the end-systolic pressure-area relationship). The result indicated that acute volume reduction favorably influenced ventricular mechanical parameters immediately after the operation. J Thorac Cardiovasc Surg 2003;125:283-9

A 57-year-old man who was in end stage renal failure underwent an aortic and mitral valve replacement for the progression of cardiac dysfunction, secondary to Staphylococcus aureus infective endocarditis. Cardiac surgery was performed using a Hemo-Concentrator during cardiopulmonary bypass, 82 months following the initiation of hemodialysis. This is the second report in the literature of a successful double valve replacement for infective endocarditis and congestive heart failure in a chronic hemodialysis patient.