Hiroyuki Tsukui

Heart valve operation in acromegaly

BACKGROUND Intractable congestive heart failure is known as a serious complication of acromegaly, but valvular heart disease rarely occurs in acromegalic patients. We experienced 5 surgical cases of valvular heart disease associated with acromegaly. We describe the features of those cases in this report. METHODS The patient characteristics and operative and pathologic findings were retrospectively studied. RESULTS There were 4 men and 1 women. Age at operation was 59 +/- 5.5 years. Cardiac lesions consisted of 1 case of aortic regurgitation associated with mitral regurgitation, 1 of aortic regurgitation, and 3 of mitral regurgitation. Operative procedures consisted of 1 double valve replacement (aortic and mitral valve replacement), 1 aortic valve replacement, and 3 mitral valve replacements. The causes of aortic valvular regurgitation were aortic valvular degeneration and aortic annular dilatation. The causes of mitral regurgitation were chordal rupture and mitral valvular degeneration. Histopathologic examination of the excised valves showed mucopolysaccharide deposits and myxomatous degeneration of the leaflets. The myocardium showed fibrosis of interstitial spaces and endocardium, and disarrangement of muscle fibers. CONCLUSIONS We report 5 successful surgical cases of valvular heart disease associated with acromegaly. Earlier operation is recommended for such cases because of acromegalic cardiomyopathy.

Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatin-resorcinol-formaldehyde glue

Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.

Surgical strategy for Kommerell's diverticulum: Total arch replacement

OBJECTIVE Kommerells diverticulum is a rare congenital aortic arch anomaly. Various surgical techniques have been reported; however, the surgical strategy is still controversial. In our institute, total arch replacement (TAR) and anatomic reconstruction of the subclavian artery (SCA) has been selected for the treatment of Kommerells diverticulum to release the vascular ring completely and prevent postoperative complications, including dissection, rupture, hand ischemia, and subclavian steal syndrome. METHODS From 2000 to 2012, 4 patients (aged 38-72 years) underwent TAR and anatomic reconstruction of the SCA for Kommerells diverticulum. All patients had a right aortic arch with an aberrant left SCA. The indications for surgery were dysphagia and dilatation of Kommerells diverticulum. TAR, using hypothermic cardiopulmonary bypass and circulatory arrest, was performed through a median sternotomy and right anterolateral thoracotomy. After resection of Kommerells diverticulum, the SCA was reconstructed with a graft. RESULTS No hospital deaths or major complications occurred, but a 72-year-old patient required prolonged hospitalization for respiratory failure. All patients were discharged from the hospital and were free of symptoms, rupture, dissection, hand ischemia, and subclavian steal syndrome at 5 months to 11 years postoperatively. CONCLUSIONS TAR is a reasonable surgical technique for Kommerells diverticulum, because it enables the vascular ring to be completely released, preventing recurrence, rupture, and dissection. Anatomic reconstruction of the SCA was effective to prevent hand ischemia and subclavian steal syndrome.

Left atrial myxoma associated with acute myocardial infarction.

We describe a patient with left atrial myxoma associated with acute myocardial infarction. Since hemodynamics were impaired even with the support of an intra-aortic balloon pump, the patient underwent removal of the tumor concomitant with coronary artery bypass grafting to the right coronary artery on the fifth day from infarction onset. In circumstances of life-threatening of myxoma associated with acute myocardial infarction, removal of myxoma with coronary artery bypass should be performed in an acute phase of myocardial infarction.

Giant extracardiac unruptured aneurysm of the sinus of Valsalva : a case report

Abstract Extracardiac unruptured aneurysm of the sinus of Valsalva (ASV) is rare and difficult to diagnose accurately by echocardiography or cardiac catheterization preoperatively. A 63-year-old woman, with dyspnea and palpitations, diagnosed with aortic regurgitation (AR) with congestive heart failure and extracardiac unruptured ASV, was referred to our hospital for surgical repair. The unruptured ASV was well visualized by magnetic resonance imaging (MRI), and diagnosed as an extracardiac type. Surgical repair was performed by aortic valve replacement and aneurysmectomy. It was concluded that early surgical repair of extracardiac ASV should be considered to prevent sudden death, and MRI is an accurate and useful method for preoperative diagnosis.

Predicting blood transfusion factors in coronary artery bypass surgery

OBJECTIVE Blood conservation has become one of the most important issues in cardiac surgery. We clarified preoperative predictors of the need for blood transfusions during coronary artery bypass graft surgery. METHODS Subjects were 89 patients--66 men (74%) and 23 women (26%) 40 to 84 years old (mean: 66.2 +/- 8.3 years)--undergoing isolated coronary artery bypass surgery from September 1997 to December 1999. Of these, 66 patients (74%) received transfusion during hospitalization and 23 (26%) did not. Nine risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion. RESULTS Independent predictors were emergency surgery (P = .0023), lower hematocrit (P = .0027), older age (P = .0043), and the presence of peripheral vascular disease (P = .0070). Optimal cutoff of hematocrit for blood transfusion was 39% and age 64 years via receiver-operating characteristics curves based on the relation between sensitivity and specificity. CONCLUSION Patients older than 64 years with hematocrit less than 39% and/or peripheral vascular disease should be treated routinely using preoperative storage of autologous blood whenever the patients condition permits. For patients undergoing emergency surgery, further studies are required, including lowering transfusion threshold and using determinants other than hematocrit.

Early outcome of folding mitral valve repair technique without resection for mitral valve prolapse in 60 patients.

OBJECTIVES Leaflet resection represents the reference standard for mitral valve regurgitation. However, the resection technique is irreversible and requires leaflet cutting and reapproximation. Folding mitral valve repair is a nonresectional technique with inversion of the prolapsed segment into the left ventricle. The present study evaluated the effectiveness of this technique. METHODS The prolapsed segment was inverted into the left ventricle vertically. A pilot suture was placed at the free edge of the leaflet. After confirming no mitral valve regurgitation with a pressure test, additional sutures were placed toward the annulus. If the test still showed mitral valve regurgitation, the suture was removed and repositioned. Ring annuloplasty was performed in all patients, except those with active infectious endocarditis. The repaired mitral valve was evaluated using echocardiography. RESULTS A total of 60 patients (37 men; mean age, 62.4 years) underwent folding mitral valve repair from January 2007 to September 2011. Of these patients, 38 (63%) had moderate and 18 (30%) had severe mitral valve regurgitation preoperatively. Folding mitral valve repair was applied to the anterior leaflet and posterior leaflet. The mean cardiopulmonary bypass time and crossclamp time were 148 and 90 minutes, respectively. No patient had systolic anterior motion. Postoperative echocardiography revealed no mitral valve regurgitation to trivial mitral valve regurgitation in 48 and mild mitral valve regurgitation in 12 patients. No patient required reoperation for recurrent mitral valve regurgitation. CONCLUSIONS Folding mitral valve repair is an easily fine-tuned technique with a pilot suture, which can be easily removed and repositioned, if unsatisfactory. This reversibility is a significant advantage of this technique. Long-term follow-up is necessary to assess the durability of this technique.

Bileaflet mechanical valve replacement: an assessment of outcomes with 30 years of follow-up †

OBJECTIVES Heart valve replacement with a bileaflet mechanical valve is a well-established procedure. However, the long-term results of valve replacement using the bileaflet mechanical valve remain unclear, especially for follow-up periods over 30 years. Additionally, it is important to identify predictors of long-term mortality and valve-related events. METHODS We performed a retrospective cohort analysis of 2727 patients (mean ± standard deviation age, 52.8 ± 1.6 years) who underwent valve replacement with a St. Jude Medical valve at our institute from 1978 to 2012. Data were collected using a questionnaire and chart review or physician contact. The cohort included 950 aortic valve replacements (AVRs), 1255 mitral valve replacements (MVRs) and 522 double valve replacements (DVRs). Follow-up was 91% complete, and the analysis included a total of 39 187 patient-years. RESULTS Operative mortality rates were 2.3% for AVR, 2.2% for MVR and 3.6% for DVR. The 30-year survival rate (actuarial method) was 38.0% (AVR, 44.5%; MVR, 34.9%; and DVR, 37.5%). The 30-year rates of freedom from valve-related mortality, thromboembolic events and bleeding events were 86.3% (AVR, 88.6%; MVR, 85.4%; and DVR, 84.3%), 83.5% (AVR, 89.8%; MVR, 80.0%; and DVR, 81.4%) and 91.5% (AVR, 94.4%; MVR, 90.1%; and DVR, 90.2%), respectively. The incidence rates of valve-related morbidity, thromboembolic events and bleeding events were significantly higher among patients with MVR and DVR than among those with AVR. Significant risk factors for late death and other late events included male sex, age >65 years and atrial fibrillation. CONCLUSIONS Low late mortality and a low incidence of valve-related events can be achieved for at least 30 years using mechanical bileaflet valve replacement. Persistent atrial fibrillation is a significant risk factor for morbidity and mortality.

Left atrial dissection

Left atrial (LA) dissection is a rare complication and is defined as a gap from the mitral or tricuspid annular area to the interatrial septum or left atrial wall. Because of its low incidence, this entity is not fully understood. LA dissection is related to mitral valve surgery as well as coronary artery disease, arrhythmia, trauma, tumor, and spontaneous occurrence. Transesophageal echocardiography is the most useful diagnostic modality for LA dissection, but multimodality investigation supports accurate diagnosis. There are two treatment options for LA dissection: surgical repair and close observation. Surgical repair involves entry closure and internal drainage. The indication for surgery should be based on the clinical presentation.

Which patients can be weaned from inotropic support within 24 hours after cardiac surgery

Inotropic support after cardiac surgery is sometimes employed for a long period without any definite criteria to wean patients from it. There are few reports describing factors influencing the inotropic support period. This study was undertaken to clarify the proper inotropic support period, especially to judge which patients can be weaned from it within 24 h. From January 2000 to December 2001, 151 patients, 88 (58.2%) with ischemic heart disease, 51 (33.8%) with valvular disease, 7 (4.6%) with congenital heart disease, and 5 (3.4%) with other heart disease, underwent cardiac surgery. The mean age was 66.2 ± 10.1 years (range 30–95); 98 patients (65%) were male. The data were analyzed retrospectively. Eighty patients (53%) were weaned from inotropic support within 24 h after cardiac surgery. Univariate analysis showed that intra-aortic balloon pumping, blood transfusion, operation time, cardiopulmonary bypass time, and aortic cross-clamping time significantly influenced the inotropic support period. Multivariate analysis indicated that intra-aortic balloon pumping, blood transfusion, and cardiopulmonary bypass time significantly influenced the inotropic support period. Intra-aortic balloon pumping, blood transfusion, and cardiopulmonary bypass time might determine the inotropic support period. Appropriate surgical procedure and methods both reducing cardiopulmonary bypass time (<75 min) and minimizing blood loss are the keys to weaning patients from inotropic support within 24 h.