Akihiro Masuzawa

One-Stage Surgical Repair for Berry Syndrome With Preoperative Diagnosis by 3-Dimensional CT

Berry syndrome is a rare congenital combination of an aortopulmonary window, an aortic origin of the right pulmonary artery, an interrupted aortic arch with a patent ductus arteriosus, and an intact ventricular septum. We report a successful one-stage surgical correction of Berry syndrome. Also, we demonstrate the importance of prompt clinical recognition with echocardiography and 3-dimensional reconstruction of computed tomography (3D-CT) and timely operation for the management of this rare cardiac anomaly.

Image-guided surgical repair of ventricular septal rupture using self-expanding device

The purpose of this study was to determine the possibility of a new surgical technique for the treatment of ventricular septal rupture after acute myocardial infarction. The operations were conducted under the guidance of real-time three-dimensional echocardiography (RT3DE) (iE33, Philips Medical Systems, Andover, MA). Six pigs were anesthetized, and after median sternotomy, the echo probe was applied directly to the surface of the heart. A ventricular septal defect (VSD) was created in all the six porcine hearts. The VSDs were closed with an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) through the right ventricular free wall under RT3DE monitoring. The procedure was successful in all the six pigs. The VSDs were precisely closed with the septal occluder under RT3DE guidance. Both left ventriculography and color-Doppler echocardiography showed no residual shunt in any of the six pigs. The use of the Amplatzer septal occluder under the guidance of real-time three-dimensional echocardiography made it possible to close the ventricular septal defect safely and successfully without the need to resort to cardiopulmonary bypass. Our results strongly suggest that the application of this new technique is feasible for the treatment of ventricular septal rupture after acute myocardial infarction.

Tacrolimus-Induced Reversible Cerebral Vasoconstriction Syndrome with Delayed Multi-Segmental Vasoconstriction

Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular syndrome characterized by multi-segmental constrictions of the cerebral arteries that resolves spontaneously within 3 months. Although RCVS is considered to be due to transient dysregulation of vascular tone, the exact pathomechanism remains unclear. We describe the case of a 15-year-old girl with RCVS induced by tacrolimus, who developed generalized seizure during the postoperative course of orthotropic heart transplantation. Magnetic resonance imaging at symptom onset showed a few vasoconstrictions accompanying brain edema and convexity subarachnoid hemorrhage. Although her neurological conditions rapidly improved after discontinuing tacrolimus, a repeat magnetic resonance angiogram demonstrated delayed progression of the multi-segmental vasoconstrictions followed by subsequent resolution. Our case demonstrates that cautious observation of the cerebral arteries using magnetic resonance angiography and careful management of vasoconstrictions with vasodilators are necessary for delayed vasoconstrictions even when the clinical symptoms improve.

In early-stage diabetic retinopathy, risk of cardiac events after implantation of sirolimus-eluting stent is higher than after coronary artery bypass surgery

BACKGROUND Patients with diabetic retinopathy (DR) have an increased risk of death from coronary heart disease and myocardial infarction. The purpose of this study was to compare the outcomes of revascularization strategies (sirolimus-eluting stent [SES] and coronary artery bypass surgery [CABG]) in patients with DR according to the stage of retinopathy: non-proliferative retinopathy (NPDR) and proliferative retinopathy (PDR). METHODS From April 2004 until February 2007, 627 patients including 51 NPDR and 62 PDR patients underwent SES implantation. For each retinopathy group, a historical comparison group at the same stages of retinopathy undergoing CABG was selected. Cardiac events were defined as a composite of cardiac death, myocardial infarction, and repeat revascularization. RESULTS The average follow-up from the time of the initial revascularization was 27.7 ± 8.5 months for NPDR-SES patients, 69.6 ± 36.6 months for NPDR-CABG patients, 26.4 ± 9.7 months for PDR-SES patients, and 68.3 ± 44.2 months for PDR-CABG patients; and Kaplan-Meier estimates of the percentages of events at 24 months were 47.0%, 22.8%, 28.5%, and 26.0%. Kaplan-Meier curves for cardiac events differed significantly between the SES group and the CABG group in NPDR patients (p = 0.04), whereas the curves did not differ significantly between the two groups of PDR patients. The adjusted hazard ratio of SES implantation for cardiac events in the entire group of DR patients was 1.75 (95% confidence interval [CI] 1.02-3.00, p = 0.04). CONCLUSIONS SES implantation is not a suitable method of revascularization in DR patients, especially in NPDR patients. CABG may become the first-choice revascularization technique for these patients.

Effect of cone reconstruction on right ventricular function in patients with Ebstein’s anomaly: a meta-analysis

OBJECTIVES Cone reconstruction (CR) is a novel technique for surgically treating the tricuspid valve and right ventricle (RV) in patients with Ebsteins anomaly. However, precise changes in the RV function after CR remain unclear. This study aimed to evaluate the RV size and New York Heart Association (NYHA) functional class by conducting a meta-analysis of reported data. METHODS The MEDLINE, EMBASE, Cochrane Library and China National Knowledge Infrastructure databases were searched for relevant studies. The variables were RV measurements, NYHA functional classes and tricuspid valve regurgitation grades. A fixed/random effects model was used to summarize the estimates of mean difference with standard error. Sensitivity analysis was conducted to ascertain the primary origin of the heterogeneity. RESULTS Nine studies that involved 210 patients were included. The results demonstrated that after CR, the functional RV volume significantly decreased, NYHA functional class improved and tricuspid valve regurgitation grade decreased. CONCLUSIONS Thus, CR appeared to be a positive approach for Ebsteins anomaly, with good results being obtained for the RV size and NYHA functional class. Because some limitations could not be overcome, studies with more data on RV and longer follow-ups are required to confirm our study results.

Homograft use in patient with tetralogy of Fallot and absent pulmonary valve.

A neonate with tetralogy of Fallot and absent pulmonary valve presented with respiratory distress due to airway obstruction after birth. He was placed on mechanical respiration. At 28-days old, he underwent pulmonary artery reduction and pulmonary homograft insertion. Ventricular septal defect patch closure was performed under cardiopulmonary bypass. His postoperative course was complicated by prolonged mechanical ventilatory support because of tracheomalacia. After 1 year of follow-up, he was in good condition without pulmonary regurgitation.