Brain damage after aortic arch repair using selective cerebral perfusion

BACKGROUND

Selective cerebral perfusion is one of the most popular methods for cerebral protection during aortic arch repair. However, causes of postoperative brain damage are not fully understood. We analyzed brain damage after aortic arch repair using selective cerebral perfusion for true aortic arch aneurysm in regard to preoperative cerebral infarction and intracranial and extracranial occlusive arterial disease.

METHODS

Over a 9-year period, 60 patients with true aortic arch aneurysm underwent aortic arch repair using selective cerebral perfusion. Postoperative brain damage was evaluated in regard to preoperative cerebral infarction detected by computed tomography, magnetic resonance imaging, or both in 50 patients and intracranial and extracranial occlusive arterial disease detected by digital subtraction angiography, magnetic resonance angiography, or both in 35 patients.

RESULTS

Seven (12%) of the 60 patients died within 30 days of operation. Postoperative brain damage occurred in 6 (10.5%) (3, coma, and 3, hemiplegia) of 57 patients; 3 patients who died without awakening were excluded. Preoperatively, old cerebral infarction was detected in 9 patients (18%), and silent cerebral infarction (lacunar infarction and leukoaraiosis) was diagnosed in 26 patients (52%). Postoperative brain damage occurred in 3 (33%) of the 9 patients with preoperative cerebral infarction and in 3 (23%) of 13 patients with negative preoperative brain findings; this excludes 2 patients who died without awakening. No patient with silent cerebral infarction had postoperative brain damage. Occlusive arterial disease was detected in 7 patients (20%). The incidence of brain damage in these patients was 71% (5/7), which was significantly greater than that of 4% (1/28) in patients without occlusive arterial disease (p < 0.001).

CONCLUSIONS

Silent cerebral infarction may not be a risk factor for postoperative brain damage. Preoperative evaluation of intracranial and extracranial occlusive arterial disease provides important information as to whether a patient might sustain brain damage after aortic arch repair using selective cerebral perfusion.

[Long-term surgical results of acute aortic dissection]

Between 1988 and 1997, 69 patients underwent surgery for acute aortic dissection: 65 patients had an acute type A (AcA) and 8 an acute type B (AcB) aortic dissection. The hospital mortalities were 16.9% for AcA and 25% for AcB. Actuarial survival rates including hospital deaths after 5 and 8 years were 70% and 58% for AcA patients and no late death or cardiovascular event occurred in AcB patients during follow-up periods. Freedom from cardiovascular events was 88% and 70% at 5 and 8 years, and freedom from reoperation was 94% at 5 and 8 years for operative survivors of AcA. There were no differences on actuarial survival rates between ascending aortic repair and arch repair, ringed-graft and suture anastomosis, and postoperatively patent false lumen and closed false lumen. There were no differences on freedom from cardiovascular events between ascending aortic repair and arch repair, and ringed-graft and suture anastomosis, however, patients with postoperatively patent false lumen showed significantly lower freedom from cardiovascular events registering 85% and 59% at 5 and 8 years compared with 94% at 5 and 8 years in patients with closed false lumen.

[Open distal anastomosis or aortic balloon occlusion technique during complete aortic arch replacement]

The technique of open distal anastomosis or application of aortic balloon occlusion catheter designed to occlude the descending thoracic aorta have been used in 33 and 19 patients, respectively, to control bleeding during the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. These two techniques allowed us a simple approach to the lesion and the avoidance of clamp injury to the fragile aortic tissue. Open distal anastomosis was applied for 91% patients of operated aortic dissection and all emergent cases, it's duration ranged from 10 to 110 minutes with an average of 58 minutes under 18.2 degrees C of lowest esophageal temperature. On the other hand, aortic occlusion balloon was inserted for mainly true aortic aneurysm patients without an emergency, and helped to maintain the perfusion pressure on a lower part of body around 50 mmHg by the 1550 ml/min in an average of perfusion flow femoral artery under 21.2 degrees C of temperature. The difference of postoperative renal and liver function evaluated by serum enzyme levels of total bilirubin, GOT, GPT, LDH, creatinine and BUN did not reach to statistical significance between the patients using open distal anastomosis and balloon occlusion, however, the incidence of postoperative complication including either renal, liver dysfunction, abdominal problem or paraplegia was significantly higher in the patient group with open distal technique. Either open distal anastomosis or aortic balloon occlusion technique would be appropriately selected according to the patient's characteristics or the condition of aortic disease to be operated.

Simultaneous measurement of the phase and group indices and the thickness of transparent plates by low-coherence interferometry

We propose and demonstrate a novel technique for simultaneous measurement of the phase index, n(p) , the group index, n(g) , and the thickness, t , of transparent plates by use of a low-coherence interferometer. The output light from a superluminescent diode is focused upon the front plane of a transparent plate that is used as the sample. The sample stage is subsequently moved until the light is focused upon the rear plane of the plate. Measurement of the stage movement distance and the corresponding optical path difference allows us to determine both n(p) and n(g) . By placing the sample between two glass plates, we measured n(p) , n(g) , and t simultaneously, with an error of 0.3% or less, for nearly 1-mm-thick transparent plates, including glass and electro-optic crystals.

Sutureless ringed graft replacement of descending thoracic aorta with extensive calcification

A 79-year-old hypertensive woman, with fusiform shaped atherosclerotic aneurysm in the descending thoracic aorta whose medial layer was maintained by an extensive solid calcium plate (porcelain aorta), was successfully treated using a sutureless intraluminal ringed graft. Spools of the ring were fixed by circumferential ligatures at both proximal and distal sites of anastomosis and a dilated segment of the aorta was replaced with the tube graft.

Replacement of the ascending aorta and aortic valve with a composite graft: operative and long-term results

The purpose of this study is to analyze our treatment experience on patients with ascending aortic aneurysms, with aortic regurgitation. From January 1974 to December 1995, 49 patients underwent replacement of the aortic valve and ascending aorta with a composite graft, in which primary operation cases were 44 and reoperation ones were 5. The Bentall technique was used in 20 patients, the button technique in 11, the interposition graft technique in 11, and a combination of the interposition graft and button technique in 7. All but one reoperation cases underwent the interposition graft technique. Hospital mortality was 30% for the Bentall technique, and 9.1% for the button technique and 9.1% for the interposition graft technique; there was no hospital mortality in the combination of the interposition graft and button technique. Hospital mortality of interposition graft technique in primary operation cases was 9.1%, and that in reoperation cases was 0%. Hospital mortality in patients underwent from 1974 to 1985 was 30.8%, 27.8% from 1986 to 1991, and 0% from 1992 to 1995. Five late deaths occurred in the Bentall group (35.7%) and one late death in the button technique (9.1%). Not late deaths in the other groups have occurred. In summary, operative mortality in Bentall technique group was higher than that of the other groups. Operative results were improved by the change of operative methods. The interposition graft technique is preferable for patients undergoing reoperation or when tension on the ostial anastomoses may occur. The button technique is best for patients with aortic dissection or inflammation involving the coronary ostia.

Successful management of left main bronchial stenosis as a rare complication of pericardiectomy

We present a rare complication of pericardiectomy and the effective management thereof. A 67-year-old female with dyspnea and upper abdominal pain was received at our department upon referral. Chest roentgenogram and cardiac catheterization preceded a diagnosis of constrictive pericarditis. Pericardiectomy was performed subordinate to median sternotomy and left anterolateral thoracotomy. Extubation was carried out on day 2 but reintubation was necessitated on the same day as a result of progressive dyspnea. Chest roentgenogram revealed an atelectasis of the left lung. Fiberoptic bronchoscopy showed left main bronchial stenosis resulting from a pulsating external structure. A postoperative computed tomogram substantiated the stenotic left main bronchus between the dilated left pulmonary artery and the thoracic descending aorta. An expandable metallic stent for the treatment of this complication was selected over other invasive procedures. Two years of follow-up reveal no complications. Accordingly, an expandable metallic stent has demonstrated its effectiveness not only on bronchial stenosis due to malignancy or tuberculosis but on benign cases such as this as well.

[Brain damage following aortic arch repair with regard to techniques of selective cerebral perfusion and preoperative cerebral lesions]

One hundred and twenty-nine aortic aneurysm patients (true 68 and dissection 61) underwent aortic arch repair from January 1987 to December 1995. Postoperative brain damage was evaluated regarding both preoperative brain lesions and techniques of selective cerebral perfusion (SCP) in that one pump for SCP until April 1992, then two pumps were employed, one for right and the other for left hemisphere of the brain. Overall hospital mortalities were 21% in true and 13% in dissecting aneurysms. Ten patients were complicated with postoperative brain damages (coma 8 and hemiplegia 2), registering 7.8% of total patients. Both history of stroke and silent cerebral infarction (SCI) detected by CT and/or MRI were considered to be positive in the mean of having preoperative brain lesions. Although there was no significant difference between incidences of postoperative brain damage in true and dissecting aneurysms, registering 11% and 4% respectively, preoperative brain lesions in true aneurysm (68%) was significantly greater than dissecting aneurysm (32%). Furthermore, the incidence of postoperative brain damage was 22% in one-pump SCP which was significantly greater than 3% in two-pumps SCP in the patients with a true aneurysm. But there was no postoperative brain complication in patients with SCI even using either one two pumps for SCP. The present data suggest two-pumps SCP is better technique for cerebral protection compared to one-pump SCP for aortic arch repair.

Tricuspid valve closure for neonatal Ebstein's anomaly

A respirator-dependent 11-day-old boy with Ebstein's anomaly is presented. His cardiac anomaly with progressive cardiomegaly was first noticed at 24 weeks' gestation on fetal echocardiography. After birth, he required mechanical ventilation because of massive tricuspid regurgitation and restricted pulmonary blood flow. The operation of tricuspid valve patch closure, resection of right atrial wall, and central shunt successfully weaned him from the respirator on postoperative day 13. Cavopulmonary anastomosis was performed without problem when the patient was 8 months of age.

[Early and late results of replacement of the ascending aorta and/or aortic arch using selective cerebral perfusion]

From 1987 to 1994, 116 patients received replacement of the ascending and/or aortic arch using selective cerebral perfusion. They were 82 male and 34 female, with average age of 64 years. There were 63 dissecting and 53 true aneurysms. Extent of replacement was: ascending aorta in 13, aortic root in 2, aortic arch in 93, and aortic root and complete arch in 8. Aortic arch replacements were composed of: 29 partial proximal aortic arch replacements, 44 complete aortic arch replacements, and 20 partial distal aortic arch replacements. Nineteen (16.4%) hospital deaths occurred. Univariate testing of pre-, intra-, and post-operative variables followed by stepwise logistic regression analyses identified elderly, ischemic heart disease, postoperative neurologic complication, cardiac dysfunction, renal failure, and massive bleeding as factors having independent association with hospital mortality. Neurologic complication was found in 10 patients (8.6%), and risk factor for this complication was preoperative peripheral vascular disease. Follow-up of hospital survivors documented an overall cumulative 5-year survive rate of 69%. There was no significant difference between dissection and true aneurysms in 5-year survive ratios, which were 63% and 82%, respectively. During follow-up periods, 18 patients died. Half of these cases were vascular deaths, caused by rupture, sudden death and secondary operation. Univariate analyses followed by stepwise Cox testing indicated that chronic obstructive pulmonary disease and a history of postoperative massive bleeding were associated with decreased later survival. Our experience suggests that selective cerebral perfusion is a safe technique for the repair of ascending aorta and/or aortic arch problems. High-risk subgroups of patients with these aortic problems can be identified by risk factors. Aggressive and careful management is necessary for such subgroups to improve early and late survival rates.

Vection with Degraded Real-World Stimuli

Psychophysical studies have revealed that the retinal periphery plays a dominant role in inducing vection, ie the visually induced sensation of self-motion. This suggests that the quality of the visual stimulus is not an important factor for vection. However, since abstract stimuli were used in these studies, it is not clear whether the quality of real-world visual stimuli could still play a critical role in inducing vection. We investigated how vection induced by real-world visual stimuli was affected when the stimuli were spatially or temporally degraded.

Stereoscopic video clips were taken through the windshield of a car driven on a sharply curved and hilly road. These clips were degraded spatially by using a mosaic effect, or temporally by using a strobe effect on a video editing system. The perceived direction and strength of vection were measured while subjects were viewing these visual stimuli presented on a 63 deg wide and 38 deg high video projection monitor. Degradation of the visual stimuli was found to have little effect on the assessment of direction in horizontal vection. Assessment of the direction of vertical vection, however, was significantly disturbed by both spatial and temporal degradation of the stimuli. Temporal degradation reduced the strength of vection significantly for both horizontal and vertical motion. In contrast, although spatial degradation of visual stimuli reduced the strength of vection in both dimensions slightly, the effect was not statistically significant. We conclude that the spatial quality of real-world visual stimuli does not play a significant role in inducing vection.

[Redo operation after surgery for aortic aneurysm and dissection]

Thirteen patients who underwent redo operation after surgical treatment of aortic aneurysm and dissection were presented. In 8 patients, redo operations were performed for aortic dissection following aortic valve replacement. A-C bypass, the Koster-Collins operation and replacement of thoracic aorta. In the other 5 patients, the reasons for redo operation were aortic root enlargement after replacement of ascending aorta and aortic valve replacement, pseudoaneurysm and aneurysmal dilatation around coronary button for the Bentall operation and recurrent aneurysm after patch aortoplasty and thoracoabdominal replacement using the Crawford's maneuver. To prevent these redo operation, adequate selection of surgical procedures and meticulous operative techniques should be required in primary operation.

Egocentric perception through interaction among many sensory systems

We perceive the egocentric position and velocity of ourselves by many senses, such as vision, proprioception and vestibular sense. Normally the information by these senses is in harmony. However, there are situations in which the information is inharmonious. When we watch a wide-screen monitor or we ride in an accelerating or turning vehicle, visual information conflicts with proprioceptive and vestibular information. Since human egocentric perception has been studied for each separate sense in the previous research, it is not clear how the integration among these senses contributes to perception of human orientation. In Experiment 1, we investigated the contribution of visual, proprioceptive and vestibular information in isolation and in combination to perception of direction of forward self-motion. An observer rode in small vehicle (vestibular information) or walked (proprioceptive information) through a narrow corridor. Many vertical bars were hung from a ceiling of the corridor. When the observer moved forward, she/he viewed expanding optic flow of the bars (visual information) through video cameras and a helmet-mounted stereoscopic display. By fastening the observer and/or the cameras at different angles, consistent or conflicting information about forward direction was given through each sense. It was found that when there was conflicting information about the direction of forward motion (a) vestibular information was more dominant than visual cute, (b) visual and proprioceptive information was linearly added with weighting, and (c) visual information was dominant for backward motion. In Experiment 2, we investigated sensory integration when we moved forward with linear acceleration. Direction of the acceleration was either forward or sideways, namely corresponding to a ride in an accelerating or turning vehicle. We developed a new method to measure sensation or self-motion more objectively by using the three-dimensional position-sensor system. Positions of observer's head, shoulder, waist and ankle were measured to find body tilt accompanied by sensation of self-motion. It was found that the body tilted towards the opposite direction of the self-acceleration and the angle of body tilt was in good agreement with the subjective amount of the accelerating sensation. The body tilt was even induced by solely visual information. This implied that visual information contributed to perception of self-acceleration as well as self-motion.

Effects on visual functions during tasks of object handling in virtual environment with a head mounted display

This study examined the effects on visual functions of a prolonged handling task within the helmet-mounted display environment. Both version eye movement and accommodative response became gradually slower during the 40-min task. Although delayed presentation of display after head movement noticeably worsened both visual responses, presentation delay after hand movement did not significantly change the sluggishness of responses. Therefore it is suggested that decreasing time delay after head movement is a more important factor in order to improve human performance of handling tasks within the HMD environment.

Extracardiac conduit composed of gutter-shaped prosthesis and pedicled pericardial valved patch for pulmonary trunk reconstruction

A conduit for reconstruction of the pulmonary trunk is presented. A Gelseal vascular prosthesis (Vascutek Ltd, Inchinnan, Scotland) was split longitudinally in two halves, and one half was used as a posterior wall of the conduit like a gutter. The anterior wall was constructed by a pedicled pericardial valved patch. Finally, the proximal anastomosis of the conduit was completed with a gusset cut from the Gelseal prosthesis. This conduit can be applied to patients who require the Rastelli procedure, and growth potential of the pedicled pericardial patch may be expected.

Vection with Real-World Stimuli

Psychophysical studies have revealed that retinal and depth periphery play a dominant role in activating vection, or visually induced sensation of self-motion. But since abstract stimuli such as random-dot patterns and vertical stripes have been used in these studies, the results are not always applicable for designing more realistic visual displays in real-world applications. Indeed, it has been shown that for human orientation, a real-world display is more effective than an abstract one (Howard and Childerson, 1994 Perception23 753 – 762). We investigated how vection was controlled by the peripheral part of a stimulus consisting of a real-world display. Stereoscopic and nonstereoscopic video clips were taken through a windshield while driving on (i) a straight, (ii) a gradually curved, and (iii) a sharply curved road at slow and fast speeds. Vection was measured with these stimuli which were presented on a 63 deg wide and 38 deg high video projection monitor. The results showed that although the stereoscopic display generally activated more forward and sideways vection than the nonstereoscopic one, the difference was barely statistically significant. When only the central 18 deg diameter of the display was presented, similar vection was activated as with a full field display. When the central 40 deg diameter of the display was occluded, vection did not change significantly, though observers found difficulty in assessing the direction of self-motion. It is concluded that retinal and depth periphery of real-world stimuli do not play a significant role in activating vection.

Effects of cardiac surgery on intellectual function in infants and children

Intellectual function was evaluated by Gesell's developmental quotient (DQ) and Binet's intelligence quotient (IQ) in 161 infants and children (61 ventricular septal defects, 49 tetralogies of Fallot, 15 transpositions of the great arteries, seven atrial septal defects, five complete atrioventricular canals, five double outlet right ventricles and 19 shunt cases; average age 3.6 years) before and after cardiac surgery. There were no significant differences in preoperative DQs and IQs among the patient groups. Although average DQ scores in 21 infants with hypothermic (13-24 degrees C) total circulatory arrest (36-70 min) were not significantly different from the preoperative values, 13 patients with an arrest time > 50 min showed a significant decrease in DQ scores. The postoperative DQ and IQ scores in patients without circulatory arrest or in shunt cases were not significantly impaired after surgery. It was concluded that cardiac surgery did not impair intellectual function in infants and children, although cerebral dysfunction might occur if circulatory arrest was > 50 min.

[Acute aortic dissection with leg ischemia]

From January of 1987 to July of 1994, 83 patients with acute aortic dissection were treated at our institution. Of these, 7 patients (8%) sustained acute leg ischemia. Angiography showed that one patient had arterial occlusion at the abdominal aorta, three had occlusion at the right common iliac artery, and one had severe right common iliac artery stenosis. Four patients with acute type A dissection underwent emergency replacement of the aortic arch and/or ascending aorta. Three of them were discharged, but one patient died due to renal failure and multiple organ failure. In three patients with acute type B dissection, one with aortic rupture was successfully treated by replacement of the descending thoracic aorta; of the other two who received bypass operations for leg ischemia, one died due to myonephropathic metabolic syndrome and sepsis which were caused by a delay in surgery. In conclusion, emergency thoracic aortic repair should be performed in acute type A dissection with leg ischemia, whereas bypass operation for ischemic leg should be considered in patients of acute type B dissection with leg ischemia when they are not complicated with rupture or visceral ischemia.

[Dislodgement of the ringed-graft--a case report]

A 70-year-old man underwent replacement of the distal aortic arch which contained a huge aneurysm using a ringed graft. He died suddenly of hemoptysis 54 months following the operation. An autopsy revealed dislodgement of the spool on the posterior aspect of the aorta. Histologic examination of the dislodged portion of the ring showed complete disruption of the intima and elastic fibers of the media. There were minimal histologic changes in the anterior portion of the anastomotic site. It is postulated that the long, kinked graft might have caused the late ring dislodgement.

[Separate perfusion of upper and lower body under mild hypothermia during operation on the thoracoabdominal aorta]

During last 7 years, we performed 24 operations on the thoracoabdominal aorta. There were 9 true and 15 dissecting aneurysms. There were two cases of ruptured aneurysm and thoracoabdominal replacement was performed as a last stage operation for total aortic replacement in 4 cases. Three cases with aortic dissection died within 30 days after surgery. Femoro-femoral bypass was used in 4 cases (1 case died of brain damage, paraplegia and MOF), left heart bypass in 5 cases and separate perfusion of upper and lower body (SPULB) under deep hypothermia in 7 cases (2 cases died of LOS and cerebrovascular accident occurred at 2 weeks after operation) and SPULB with mild hypothermia in 8 cases for circulatory support. There was one case of renal dysfunction and transient mild liver dysfunction occurred in 7 cases. There was no evidence on relationship between surgical outcome and methods of circulatory supports, but we recently prefer SPULB under mild hypothermia for thoracoabdominal surgery since intraoperative massive bleeding and cardiac arrest can be easily treated and major organs can be protected by introducing hypothermia in this perfusion technique.

Proposal of a working left heart model with a heterotopic transplantation technique in rats

BACKGROUND

A heterotopically transplanted rat heart model described by Ono and Lindsey in 1969 has been widely used as a fundamental animal model of heart transplantation. However this "nonworking" model is greatly different from the orthotopic heart in view of left ventricular work, in which the experimental results obtained may not always reflect the clinical setting with an orthotopic transplanted "working" heart. We herein propose a new "working" left heart model in rats using a heterotopic abdominal transplantation technique by modifying the method of Ono and Lindsey.

METHODS

First, a donor heart graft and a recipient were prepared in the conventional fashion. Second, the donor heart was tailored by the ligation of main pulmonary artery and the removal of tricuspid valve and interatrial septum. Third, the ascending aorta and right atrium of the donor heart were anastomosed to the infrarenal abdominal aorta and to the inferior vena cava of the recipient, respectively. Consequently, the left atrium and ventricle of heart graft were loaded with the blood from the right atrium through the interatrial communication.

RESULTS

This surgical procedure required an average of 58 minutes and had negligible operative risk. The donor left ventricle produced a systolic blood pressure almost equal to the recipient's aortic pressure and maintained vigorous beat.

CONCLUSIONS

This model is easily reproducible and would be useful for various studies on heart transplantation.

[Hemodynamic response to pericardiectomy in the patients with constrictive pericarditis: with reference to surgical approaches and responses to exercise]

Between 1975 and 1994, we performed 20 pericardiectomies for 19 patients with constrictive pericarditis (CP) through a median sternotomy (13 cases), a left thoracotomy (2 cases), a median sternotomy combined with a left thoracotomy (4 cases) or a median sternotomy under ECC (1 case). One patient died from LOS at 1st POD due to myocardial failure. Pericardiectomy through a median sternotomy decreased RA pressure but PAW pressure did not decrease in some patients. On the contrary, pericardiectomy through either a left thoracotomy or a median sternotomy combined with a left thoracotomy decreased PAW pressure as well as RA pressure significantly. Responses to bicycle exercise demonstrated marked elevation of RA and PAW pressures even in a mild case of CP, so that the exercise testing seems to be useful for early detection of CP and evaluation of the operative results.

Heading judgments during active and passive self-motion

Previous studies have generally considered heading perception to be a visual task. However, since judgments of heading direction are required only during self-motion, there are several other relevant senses which could provide supplementary and, in some cases, necessary information to make accurate and precise judgments of the direction of self-motion. We assessed the contributions of several of these senses using tasks chosen to reflect the reference system used by each sensory modality. Head-pointing and rod-pointing tasks were performed in which subjects aligned either the head or an unseen pointer with the direction of motion during whole body linear motion. Passive visual and vestibular stimulation was generated by accelerating subjects at sub- or supravestibular thresholds down a linear track. The motor-kinesthetic system was stimulated by having subjects actively walk along the track. A helmet-mounted optical system, fixed either on the cart used to provide passive visual or vestibular information or on the walker used in the active walking conditions, provided a stereoscopic display of an optical flow field. Subjects could be positioned at any orientation relative to the heading, and heading judgments were obtained using unimodal visual, vestibular, or walking cues, or combined visual-vestibular and visual-walking cues. Vision alone resulted in reasonably precise and accurate head-pointing judgments (0.3 degrees constant errors, 2.9 degrees variable errors), but not rod-pointing judgments (3.5 degrees constant errors, 5.9 degrees variable errors). Concordant visual-walking stimulation slightly decreased the variable errors and reduced constant pointing errors to close to zero, while head-pointing errors were unaffected.

[Mitral valvuloplasty for an infant with congenital mitral stenosis-- report of a case]

A 7-month-old infant, who underwent repair of coarctation of the aorta four months ago, was readmitted for heart and respiratory failure. Preoperative serial echocardiographic studies revealed progression of mitral valvular and subvalvular stenosis. At operation the mitral valve apparatus was found to be funnel-shaped type of congenital mitral stenosis. Chordae fenestration, papillotomy and commissurotomy were performed. Intraoperative transesophageal echocardiography demonstrated increased inflow through the mitral valve apparatus. Postoperative course was uneventful, and she was discharged 28 days after operation.