Daisuke Onohara

Characteristics and treatment strategies of mitral regurgitation associated with undifferentiated papillary muscle

PurposeIn this report we review our experience of operations on mitral regurgitation associated with abnormal papillary muscles/chordae tendineae of the mitral valves and discussed the clinical characteristics, operative findings, and treatment strategies.MethodsUndifferentiated papillary muscle was defined as a hypoplastic chordae tendineae with anomalous formation of papillary muscles attached to the mitral valves directly. Consecutive 87 patients undergoing surgery for mitral regurgitation at our institution were reviewed and 6 of them had undifferentiated papillary muscle.ResultsThe underlying mechanism of regurgitation was prolapse at the center of the anterior leaflet in 3 cases and tethering, a wide area of myxomatous degeneration, and annular dilatation in one case, respectively. Five patients underwent mitral valve plasty and 1 patient received replacement. Anomalous formation of chordae tendineae was corrected by resection and suture with transplantation at the tip of the leaflet to which abnormal chordae were attached in 2 cases, while resection and suture with chordal shortening was performed in 1 case, and chordal reconstruction using artificial chordae was employed in 2 cases. There was no operative death, and postoperative echocardiography showed no residual regurgitation in any of the cases.ConclusionsMitral regurgitation associated with undifferentiated papillary muscle resulted from prolapse or tethering and impaired flexibility of leaflets. It was possible to successfully treat the patients by mitral valve plasty unless complex congenital cardiac malformation coexisted. Detailed examinations of attached papillary muscle by echocardiography and intraoperative inspection are necessary and surgical techniques should be selected appropriately in each case.

Consideration of prosthesis-patient mismatch and left ventricular mass regression after implantation of the Carpentier-Edwards pericardial valve in elderly Japanese patients: body surface area may be irrelevant.

The assessment of prosthesis patient mismatch (PPM) for small aortic annulus is important for prognosis after aortic valve replacement (AVR). Recent investigations have demonstrated that PPM occurs in AVR patients with an indexed effective orifice area (iEOA) of less than 0.85 cm2/m2. We investigated hemodynamic performance and left ventricular mass (LVM) regression after AVR. Eighteen patients who underwent AVR using a 19-mm Carpentier-Edwards pericardial (CEP) valve without annular enlargement were studied by echocardiography and Doppler examination 4 months after AVR. Patients were divided into two groups on the basis of their body surface area (BSA); the smaller BSA (group S, 1.14–1.36 m2, nine patients) and the larger BSA (group L, 1.40–1.83 m2, nine patients). Of these 18 patients, ten underwent isolated AVR, and five underwent AVR with coronary artery bypass graft; (i.e., double valvular replacement, AVR with maze procedure, and AVR with mitral valvulophasty. There were no statistically significant differences between the two groups, except for age (group S, 78.3 ± 2.5 years; group L, 73.6 ± 2.4 years). There was no significant difference for the iEOA during the late phase at rest (group S, 1.10 ± 0.26 cm2; group L, 1.02 ± 0.28 cm2). However, there was a significant difference for the LVM regression between the preoperative and postoperative values (group S, 243 ± 23.6 mg/cm2 [pre], 190 ± 16.9 mg/cm2 [post]; group L, 302 ± 13.7 mg/cm2 [pre], 199 ± 16.7 mg/cm2 [post]). In elderly Japanese patients with a BSA of less than 18 m2, we demonstrated LVM regression and avoidance of PPM after implantation of the aortic 19-mm CEP valve.

Deep Vein Thrombosis Associated with Iliac Lymph Node Metastasis of an Unknown Primary Tumor: Report of a Case

Secondary deep vein thrombosis associated with iliac lymph node metastasis of an unknown primary tumor has not been previously reported. The patient was a 57-year-old male with persistent right leg edema. Computed tomography demonstrated a mass surrounding the right external iliac vessels, and deep vein thrombosis in the right external iliac and femoral veins. Physical, laboratory, and imaging examinations did not reveal any further tumor. The patient was diagnosed with deep vein thrombosis associated with right iliac lymph node metastasis of an unknown primary tumor. Complete resection of the tumor along with the involved vessels and vascular reconstruction was performed.

Survival and quality of life of octogenarians who underwent mechanical valve replacement at a younger age

PurposeMechanical valve replacement is associated with complications, however, there is little information on the quality of life (QOL) of octogenarians who had undergone mechanical valve replacement at a relatively younger age. We examined survival, valve-related events, and the QOL of octogenarians who had undergone mechanical valve replacement.MethodsA total of 56 octogenarians who underwent mechanical valve replacement between 1969 and 1997 (age at the time of surgery, 65.6 ± 6.7 years), completed a questionnaire on survival, valve-related events, and QOL (basic activities of daily living, instrumental activities of daily living, mental health).ResultsThe mean follow-up was 12.4 ± 6.6 years, and the cumulative follow-up period was 642.4 patient-years. Six valve-related deaths (0.9%/patient-year) were registered during the follow-up. Furthermore, 11 valverelated events (1.8%/patient-year) were recorded. The mean age of the 21 survivors was 82.9 ± 1.8 years, and 19 of the survivors lived at home. Their QOL was excellent.ConclusionThe valve-related deaths and events in octogenarians who had previously undergone mechanical valve replacement at a younger age were within acceptable limits. The QOL was similar to that of octogenarians described in previous studies.

Aortic valve replacement with 17-mm St. Jude Medical Regent prosthetic valves for a small calcified aortic annulus in elderly patients.

PurposeThe aim of this study was to investigate the outcome of aortic valve replacement (AVR) performed with a 17-mm St. Jude Medical Regent prosthetic valve (17SJMR) for an aortic annulus ≤19 mm in elderly patients aged ≥65 years.MethodsSix female patients (age 73.0 ± 5.1 years, body surface area 1.43 ± 0.07 m2) underwent AVR between October 2005 and February 2008.ResultsPeak transaortic pressure gradient, which was 80.8 ± 31.0 mmHg preoperatively, decreased to 31.0 ± 4.2 mmHg postoperatively (P < 0.01) and to 21.7 ± 1.5 mmHg long term (P < 0.01). The left ventricular mass index, which was 112.1 ± 10.6 g/m2 preoperatively, also significantly decreased to 101.4 ± 15.0 g/m2 postoperatively and to 88.3 ± 14.8 g/m2 long term (P < 0.01). Subjective symptoms diminished in all patients, and neither mortality nor hemorrhagic complications occurred. The postoperative mean effective orifice area index was 0.91 ± 0.04 cm2/m2.ConclusionA favorable outcome was obtained by aortic valve replacement with the 17SJMR. Patients showed improved postoperative hemodynamic performance without valve-related complications.

Co-Existence of Severe Coarctation of the Aorta and Aortic Valve Stenosis in a 65-Year-Old Woman: A Case Report

Coarctation of the aorta is usually diagnosed and corrected early in life. Survival to more than 60 years of age of a patient with unrepaired coarctation of the aorta is extremely unusual, and the optimal management strategies for such patients are controversial. We describe the case of a woman who was first diagnosed as having coarctation of the aorta and aortic valve stenosis at the age of 65 years and underwent successful aortic valve replacement.

Ruptured thoracic descending aortic aneurysm coexisting with DeBakey type IIIb aortic dissection

We have encountered a rare case of ruptured true thoracic aortic aneurysm coexisting with DeBakey type IIIb aortic dissection. The patient was a 67-year-old woman who had a past history of hypertension and cerebral infarction. She experienced DeBakey type IIIb acute aortic dissection, and initially conservative medical treatment was carried out. However, the patient suddenly went into shock, and emergency contrast-enhanced computed tomography revealed the presence of a ruptured true thoracic aortic aneurysm coexisting with the type IIIb dissection. Replacement of the descending aorta was performed through a left thoracotomy using circulatory arrest and deep hypothermia. The rupture site and intimal tear were located in the middle of the aneurysm. Open proximal and distal anastomoses were carried out using a 22 × 10 mm gelatin-covered Dacron graft. The patient was discharged from our hospital uneventfully on the 33rd postoperative day.