[Surgical treatment of left ventricular-right atrial communication complicated with aortic and mitral valves regurgitation: report of a case]

A 50-year-old man with a heart murmur from early childhood and a one year history of general fatigue was admitted. Cardiac examination showed a left ventricular-right atrial (LV-RA) communication, and aortic and mitral valve regurgitation (III/IV). At surgery, the LV-RA communication was located in the atrioventricular membranous portion 3 mm above the septal leaflet of the tricuspid valve. The etiology of the LV-RA communication was congenital and valvular diseases were acquired changes caused by sclerosis due to infected endocarditis or hypertension. The diameter of the LV-RA communication defect was 6 mm, and the fibrous tissue around the defect was closed directly. Next, double-valve replacement was performed safely. However, the day after surgery, the patient developed complete atrioventricular block and implantation of a DDD pacemaker was required. He was discharged without other complication. We recommend the careful closure of the LV-RA communication defect, if the defect is small and rich in fibrous tissue.

[Surgical repair of extracardiac unruptured aneurysm of the sinus of Valsalva; report of a case]

A 65-year-old man presented with a 6 year history of dyspnea. An unruptured aneurysm of sinus of Valsalva and aortic regurgitation had been detected at another hospital a year previously, and he was referred to our hospital for surgery. At operation, an extracardiac saccular aneurysm was widely localized to the noncoronary sinus of Valsalva and protruded into the left atrium. The aneurysm of the sinus of Valsalva (ASV) was repaired with patch closure using a dacron sheet, and aortic valve replacement was performed with a 21 mm Carpentier-Edward valve. However, there was uncontrollable bleeding from the patch suture line, so ascending aorta replacement and repair of the Valsalva sinus were additionally needed. He was discharged without any postoperative complication 7 weeks after operation. Cases of an ASV protruding into the left atrium are very rare. We recommend remodeling of the aortic root with wide replacement of 1 sinus for extracardiac succular ASV, because the tissue around the ASV is so fragile.

[Selection of surgical strategy for abdominal aortic aneurysm coexisting with coronary artery disease; one-stage versus two-stage, and off-pump versus on-pump]

BACKGROUND

In patients having a combination of severe coronary artery disease (CAD) and expanding abdominal aortic aneurysm (AAA), one-stage operation of simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended.

METHODS AND RESULTS

Of 96 patients (94 men, average 65 year) with AAA and CAD, 21 patients underwent one-stage operation of simultaneous CABG and AAA repair (Group A-1: off-pump CABG in 10 and on-pump in 11), and 75 underwent two-stage operation of CABG followed by AAA with an interval of less than 6 months in 23 patients (Group A-2) and more than 6 months in 52 patients (Group B). Baseline characteristics were similar between the one-stage and two-stage groups, and off-pump and on-pump subgroups, except the proportion of single vessel disease. Mean number of distal anastomoses was significantly lower in the off-pump subgroup than in the on-pump subgroup (p = 0.011) and the two-stage group (p = 0.0057). There was 1 hospital death among on-pump patients but none among off-pump patients. Mortality rate was 4.8% in the one-stage group. Two patients (8.7 &) in the two-stage group, who had AAA was 7.0 cm and 7.5 cm diameter, died of AAA rupture prior to repair. The 10-year all death free rates were 44% in Group A (A-1 and A-2), and 86% in Group B (p = 0.0004).

CONCLUSIONS

Our data suggest that one-stage operation with off-pump CABG is an attractive option in selected patients with a large AAA (> 7 cm).

[Repair for atrioventricular valve regurgitation using autologous pericardium: report of a case]

A 13-year-old boy with [SLL] single left ventricle first underwent ventricular septation using a dacron patch at 3 years of age. Eight years after the first surgery, he presented with general fatigue on exertion as the chief complaint. Right-sided atrioventricular valve regurgitation, and dilatation of the right heart were diagnosed. Eleven years after surgery, right heart failure was uncontrollable by medicine, and 2nd surgery was performed. At operation, the right-sided heart valve leaflet was tightly adherent to the dacron septation patch, and valve plasty was judged impossible. We repaired the right-sided atrioventricular valve using an autologous pericardial valve leaflet and sub-valvular tissue. The postoperative course was uneventful, and he has been free from any complication for 33 months.

[Severe tricuspid regurgitation late after aortic and mitral double valve replacement; report of a case]

A 59-year-old man had undergone aortic and mitral valve replacement (DVR) for rheumatic aortic and mitral valve stenosis 15 years ago. At that time, echocardiography did not detect tricuspid regurgitation (TR), and catheterization data showed right atrial pressure v wave of 8 mmHg and pulmonary artery pressure of 27/12 (17) mmHg. One year after DVR, hepatomegaly and jugular venous dilatation appeared, and after 5 years edema of both legs became apparent. After 7 years, chest X-ray showed an increase of cardio-thoracic ratio, and for the first time, echocardiography detected mild TR. Fifteen years after DVR, severe general fatigue, shortness of breath and hepatomegaly could not be controlled with medication. Catheterization data showed right atrial pressure v wave of 23 mmHg and pulmonary artery pressure of 28/13 (17) mmHg. Right ventriculography showed progression of severe TR. Tricuspid valve replacement (TVR) was performed using a St. Jude Medical 31 M mechanical valve under natural cooling and heart beating. The tricuspid valve was only slightly thickened and no subvalvular abnormalities were seen other than a severely dilated tricuspid annulus. Postoperative course was uneventful and he was discharged 44 days after the TVR. He is currently doing well 6 years after the TVR. All terms, he did not have pulmonary hypertension or left-side heart problems. We suspect that the cause of TR was not secondary, and was included in the category of isolated TR. If the left heart is completely treated, as in this case, it is important to follow-up for signs of right heart failure, before TR is detected.

[Early and mid-term results of all arterial graft coronary artery bypass grafting using bilateral internal thoracic and radial arterial conduits]

From March 1996 to May 2000, 41 patients [age 39-78 (mean 63.5 +/- 8.8) years, 90.2% male] underwent all arterial multiple coronary artery bypass grafting (CABG) using bilateral internal thoracic (BiITA) and radial (RA) arterial conduits. The reason for using RA was that the right gastroepiploic artery (RGEA) was small or occluded on preoperative angiography, a history of upper abdominal surgery or disease, or the right coronary arterial lesion was proximal and mild. The BiITA were used as in situ grafts and the proximal anastomosis of RA was to the ascending aorta in all cases. All patients underwent conventional elective CABG with median sternotomy using cardiopulmonary bypass. The mean number of anastomoses was 3.3 +/- 0.5 branches and complete revascularization rate was 80.5%. Postoperative follow-up averaged 20 months and the longest was 50 months. There was no early death, and overall graft patency 2-3 weeks after surgery was 96.2% (LITA 94.0%, RITA 97.6%, RA 97.6%). Four-year actuarial survival rate was 96.4 +/- 3.5% (1 patient: 9 months, no cardiac death), and cardiac event-free rate after surgery was 89.7 +/- 4.9% [4 patients: percutaneous transluminal coronary angioplasty (PTCA)]. However, once patients were discharged from hospital, cardiac event-free rate was 100%. These excellent results suggest that all arterial graft CABG was satisfactory, and RA can be used as a third suitable arterial bypass conduit, if RGEA cannot be used or is unsuitable for use.

[Dissecting aneurysm of ventricular septum following acute inferior myocardial infarction]

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

[Cardiovascular effects of colforsin daropate hydrochloride for acute heart failure after open heart surgery]

Colforsin daropate hydrochloride (COL) is a novel drug for the treatment of acute heart failure. COL stimulates adenylate cyclase directly and produces positive inotropic and vasodilator effects accompanied by the increase in cellular cAMP. We investigated its cardiovascular effects for 9 patients who showed low cardiac index (< 3.0 l/min/m2) after open-heart surgery in ICU. After 2 or 3 hours from administration of COL, heart rate and cardiac index increased, and pulmonary artery pressure and central venous pressure decreased significantly, but blood pressure and systemic venous oxygen saturation did not show significant change. In conclusion, COL improved hemodynamics through positive inotropic and vasodilator effects without hypotension. We should investigate more proper usage of this drug to avoid such side effects as tachycardia and arrhythmia, which occurred in some cases.

Successful prevention of recurrent ventricular fibrillation by intravenous isoproterenol in a patient with Brugada syndrome

Intravenous administration of isoproterenol restored the ST-segment configuration to nearly normal in the right precordial leads and completely prevented spontaneous VF attacks in a patient with Brugada syndrome. The formation of a Brugada-type ECG has been attributed to the transmural dispersion of repolarization of the right ventricular epicardium and related to modulation of the autonomic nervous system. Our case may provide clues to the pathophysiological mechanism of this syndrome.

[Early and mid-term results of elephant trunk method using stent graft during total arch replacement]

Combined therapy of stent graft implantation and open surgery is an alternative method for aortic aneurysm. Seven patients with aortic aneurysm [annulo aortic ectasia (AAE) + Marfan syndrome (4), AAE + arch aneurysm + s/o Behçet disease (1), acute dissected aneurysm (type A) (1), thoracic aortic true aneurysm (1)] were successfully treated by means of elephant trunk method using a stent graft during total arch replacement. There was no complication related to the stent graft during the perioperative period. Postoperative computed tomographic scans were performed 1 and 6 months later. There was no endleak and no migration, and the aortic diameter around the stent graft was not changed in six patients. However, one patient showed thrombus around the stent graft, because of endleak 2 months after the operation. Such patients should therefore have careful long-term follow-up.

Coronary artery bypass grafting in 105 patients with hemodialysis-dependent renal failure

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.

Biventricular hypertrophic cardiomyopathy with right ventricular outflow tract obstruction associated with Noonan syndrome in an adult

This report describes an adult patient with Noonan syndrome accompanied by biventricular hypertrophic cardiomyopathy causing isolated right ventricular outflow tract obstruction. Biventricular hypertrophic cardiomyopathy causing right- and/or left-side outflow tract obstruction, as well as valvular pulmonary stenosis, is relatively common in infants with Noonan syndrome. However, this condition without a dysplastic pulmonary valve, or indeed any polyvalvular dysplasia, is rare in adults with Noonan syndrome. Treatment with a beta-adrenergic receptor blocking agent improved the patient's symptoms. Because neither the etiologic and prognostic relationship nor the genetic linkage between hypertrophic cardiomyopathy associated with Noonan syndrome and non-syndromic hypertrophic cardiomyopathy is clearly defined, clinicopathological findings and further follow-up may provide important evidence for the pathogenesis of hypertrophic cardiomyopathy.

[A case of a left atrial primary malignant fibrous histiocytoma]

Primary malignant fibrous histiocytoma (MFH) of the heart is very rere. We report a case of a primary intracardiac MFH. A 50-year-old woman underwent an operation for congestive heart failure due to left atrial (LA) tumor. Cardiac echocardiogram showed the tumor attached to the septal wall and posterior wall of LA. We extendedly resected the tumor with septal and partially posterior wall and reconstructed there with pericardial substitute. Pathological diagnosis was MFH. Although she did well postoperatively, cardiac echocardiogram showed a recurrent tumor in the LA at 10 days after operation. She developed respiratory failure, and chest and abdominal CT demonstrated metabolism to the lung, liver and bladder at post operative 47 days. At 77 days after operation, she expired. The prognosis of MFH is poor despite surgery. We recommend extended surgery, if the LA tumor had wide base attached to the septal or posterior wall.

Comparison of electrocardiographic findings in patients with AL (primary) amyloidosis and in familial amyloid polyneuropathy and anginal pain and their relation to histopathologic findings

To assess the prevalence of chest pain and ischemic electrocardiographic (ECG) changes and relate them to histopathologic findings of coronary arteries in cardiac amyloidosis, 33 patients with AL (primary) amyloidosis and 60 patients with familial amyloid polyneuropathy (FAP) were examined. Five patients (15%) with AL amyloidosis had recurrent anginal pain with exertion and 2 of them also experienced anginal pain after orthostatic hypotension. The chest pain was associated with transient downsloping or horizontal ST-segment depression with or without T-wave inversion in right precordial leads, whereas the remaining patients with AL amyloidosis and all patients with FAP did not show anginal pain or ischemic ST-T changes. Histologic sections of coronary arteries were obtained in 12 patients with AL amyloidosis, including 4 of the 5 patients who had angina pectaris and in 25 patients with FAP. Three patients with anginal pain had variable degrees of stenoses of the intramural coronary arteries by amyloid deposition predominantly in the media with normal or nearly normal epicardial arteries. One patient with AL amyloidosis who had effort angina showed marked stenosis and complete occlusion of the small coronary vessels by transmural amyloid deposition. The remaining 8 patients with AL amyloidosis and 25 with FAP without chest pain did not exhibit any stenosis or occlusion of both the epicardial and intramural vessels. These findings suggest that ischemic ST-T changes with chest pain are not so rare in patients with AL amyloidosis, and that markedly decreased myocardial oxygen supply due to diffuse stenotic or occlusive disease of the small coronary vessels by amyloid deposition contributes to the development of clinically significant ischemic heart disease in these patients.

[The efficacy of HFJV (high frequency jet ventilation) for ARDS (adult respiratory distress syndrome) following total arch replacement]

A 40-year-old man was admitted to the hospital with shock due to acute aortic dissection (type A of Stanford classification). The emergent total arch replacement was performed with the retrograde cerebral perfusion uneventfully. At the 3rd day after the operation, bilateral infiltrates were recognized on the frontal chest radiograph. The oxygenation was gradually decreased to less than 200 mmHg of PaO2/FiO2 in proportion with the growth of infiltrates and increase of LDH in blood. Steroid therapy was not effective. So then HFJV was introduced to improvement of hypoxygenation at the 16th day after the operation. HFJV made PaO2/FiO2 improve immediately to more than 300 mmHg and the inspiratrory pressure decrease to less than 30 mmHg. Bilateral infiltrates were diminished by HFJV. LDH in blood decreased apparently. HFJV had been used together during 15 days. The respirator was weaned at the 46th day after the operation. In this clinical course, the change of PaO2/FiO2 had the negative correlation with that of LDH in blood.

Coronary microvascular response to intracoronary administration of nicorandil

Nicorandil is an antianginal drug that causes potent coronary vasodilation of both epicardial and resistance vessels. To measure the dose-response kinetics of bolus injections of intracoronary nicorandil and to compare the vasodilatory response to nicorandil with that of intracoronary papaverine in humans, coronary blood flow velocity was measured in 30 patients using a 3Fr intravascular Doppler catheter. Continuous intravenous nitroglycerin 6 to 8 micrograms/min was infused to achieve maximal vasodilation of the epicardial vessels. Bolus doses of nicorandil dissolved in warmed saline solution were injected into the left (0.1, 0.2, 0.5, 1.0, 1.5, and 2.0 mg) and right (0.1, 0.2, 0.4, 0.8, 1.0, and 1.5 mg) coronary arteries. Intracoronary nicorandil caused a dose-dependent increase in coronary flow velocity and a decrease in coronary vascular resistance. Maximal vasodilatory effects equivalent to those obtained with 12 +/- 2 mg of intracoronary papaverine were induced with nicorandil 1.5 mg in the left coronary artery, and effects similar to those of 10 +/- 2 mg of papaverine were produced with nicorandil 1.0 mg in the right coronary artery. The time from injection of nicorandil to the onset of maximal hyperemia and duration of hyperemia were significantly shorter after nicorandil than after papaverine in both coronary arteries. Each dose of nicorandil produced no clinical symptoms and fewer changes in systemic hemodynamics and electrocardiographic QT intervals than did papaverine. These results suggest that a bolus administration of intracoronary nicorandil can safely, quickly, and reliably induce maximal coronary hyperemia comparable to that achieved with intracoronary papaverine in humans.