Mitsuru Yuzaki

Late Results of Mitral Valve Repair With Glutaraldehyde-Treated Autologous Pericardium

BACKGROUND Mitral valve repair is an established surgical procedure for treating severe organic mitral regurgitation. The mechanisms of mitral regurgitation due to infective endocarditis include rheumatic disease and congenital diseases such as a lack of leaflet tissue, and thus additional material is required to create a functional coaptation surface. We review our experience with 139 patients who underwent mitral valve repair with glutaraldehyde-treated autologous pericardium to treat organic mitral regurgitation between March 1992 and November 2011. METHODS Mitral valve disease mainly consisted of infective endocarditis in 51 patients (active, n = 32; healed, n = 19) and rheumatic disease in 47. This procedure was also applied to 12 patients who required reoperation after mitral valve repair for degenerative, congenital, or rheumatic mitral regurgitation. The mean follow-up was 4.5 ± 4.3 years (maximum 19.1). RESULTS Actuarial survival at 10 years was 84% ± 5%. Eleven reoperations proceeded at a mean of 68 months after surgery. The causes of reoperation were rheumatic disease progression (n = 4), infection (n = 3), patch dehiscence (n = 2), progressive fibrosis of the remaining mitral valve tissue after infective endocarditis (n = 1), and patch tear (n = 1). Mitral valves were replaced in 8 patients and re-repaired in 3 patients. The autologous pericardium was not calcified at the time of reoperation. The rate of freedom from reoperation was 82% ± 7% at 10 years. CONCLUSIONS Mitral valves that might otherwise require replacement can be durably and predictably repaired using glutaraldehyde-treated autologous pericardium.

Clinical Outcomes of Redo Valvular Operations: A 20-Year Experience

BACKGROUND A higher operative mortality rate has been reported after redo valvular procedures than after the primary operation. METHODS Outcomes of 330 consecutive patients undergoing 433 redo valvular operations at our institute during a 20-year period (January 1990 to December 2010) were reviewed retrospectively. The mean follow-up was 6.4 years (range, 0.05 to 1.3 years). Logistic regression analysis was used to identify factors associated with hospital death. RESULTS The overall hospital mortality rate was 6.7% (29 of 433 procedures). Logistic regression analysis identified only advanced New York Heart Association (NYHA) class as an independent predictor of hospital death. Overall survival at 5, 10, and 15 years was 83.6%±2.2%, 70.7%±3.4%, and 61.5%±4.5%, respectively. The 5-, 10-, and 15-year survivals for the first redo vs more than second redo groups were 86.5%±2.4% vs 74.7%±5.5%, 71.8%±3.9% vs 66.8%±6.6%, and 60.2%±5.7% vs 63.1%±7.2%, respectively (log-rank P=0.505). The 5- and 10-year survivals for NYHA class I/II vs III/IV patients were 91.5%±2.1% vs 70.4%±4.5% and 77.8%±4.1% vs 58.5%±5.6%, respectively (log-rank p<0.005). CONCLUSIONS Redo valvular operation in NYHA class III/IV patients is associated with high hospital death and poor long-term survival. To achieve low hospital death and good long-term survival, redo operations, including more than third redo operations, should be performed in patients with lower NYHA class.

Successful Treatment for Infected Aortic Aneurysm Using Endovascular Aneurysm Repairs as a Bridge to Delayed Open Surgery

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery.

Clinical outcomes of open heart surgery in patients with atopic dermatitis

Atopic dermatitis is a skin condition often complicated by colonization with Staphylococcus aureus, which increases the risk of infective endocarditis, skin cellulitis and osteomyelitis. Positive cultures for Staphylococcus aureus are obtained from 70% to 80% of wounds in patients with mediastinitis. Thus sternotomy carries increased risk of mediastinitis in patients with atopic dermatitis. We retrospectively reviewed 25 patients with atopic dermatitis who underwent cardiac surgery via a median sternotomy or thoracotomy from January 1997 to September 2010 at our institution. Postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus was found in 3 patients who had a median sternotomy. They were ultimately discharged in good condition. No mediastinitis occurred in patients undergoing thoracotomy. Mediastinitis may occur due to direct exposure of the bone marrow to methicillin-resistant Staphylococcus aureus in patients with atopic dermatitis whose skin is colonized with such bacteria. Thoracotomy may be a better surgical approach in patients with atopic dermatitis who require thoracic surgery.

Survival After Simultaneous Repair of Bichamber Cardiac and Pulmonary Vein Rupture Caused by Blunt Chest Trauma

A 44-year-old woman was transferred to our institution because of blunt chest trauma. Transthoracic echocardiography revealed decompression of the right ventricle resulting from pericardial effusion. Her hemodynamic condition was worsening gradually, and the decision was made to take the patient to the operating room. After releasing a large amount of clotting blood within the pericardial cavity, catastrophic hemorrhage occurred. Under better visualization after the patient was placed on cardiopulmonary bypass, we identified a 5-cm longitudinal tear and a 2-cm tear in the right atrium (RA), a 2-mm tear in the right ventricle (RV), and a 5-mm tear in the right lower pulmonary vein (PV). Those tears were repaired successfully with 5-0 polypropylene sutures.

Ortner Syndrome Associated With Aortic Pseudoaneurysm After Repair of Aortic Coarctation 30 Years Previously

A healthy 48-year-old woman with hypertension was referred to our hospital because of an aortic pseudoaneurysm. She had undergone a replacement of the descending aorta by a 16-mm Dacron graft for aortic coarctation via a left thoracotomy 30 years before. Sudden onset of hoarseness had been presented 1 month previously, and exploration by flexible fiberoptic laryngoscopy for the causes of hoarseness revealed paralytic left vocal cord (Figure 1 and online-only Data Supplement Movie I). Three-dimensional computed tomography showed aortic pseudoaneurysm with a maximum diameter of 50 mm distal to the left subclavian artery, indicating that the pseudoaneurysm had possibly developed at the proximal anastomotic site of a previous operation (Figure 2), and the diameter of the previous Dacron prosthetic graft had dilated by ≈1.3 times. Figure 1. A flexible fiberoptic laryngoscopy reveals complete left vocal cord paralysis. Figure 2. Three-dimensional computed tomography …

Repair of an adult aorto-pulmonary artery fistula associated with a ruptured aortic arch aneurysm using a frozen elephant trunk technique

We describe the repair of an acute aorto‐pulmonary artery fistula in a 82‐year‐old patient with a ruptured aortic arch aneurysm using a frozen elephant trunk technique.

Illuminating the optimal anastomosis site with optical coherence tomography in coronary artery bypass surgery

Optical coherence tomography (OCT) is a light-based imagingmodality that can be used to assess the structure of the arterial wall and the characteristics of intraluminal plaques. We present images of a patient undergoing coronary artery bypass graft surgery, in which OCT was helpful in determining the optimal site for bypass grafting of a diffusely diseased left anterior descending (LAD) artery. A 67-year-oldmale with a history of hypertension, hyperlipidemia, diabetes, smoking, and diabetic nephropathy on hemodialysis presented with congestive heart failure. Transthoracic echocardiography revealed an ejection fraction of 40% and a dilated left ventricle with moderate mitral regurgitation. Coronary angiography demonstrated diffuse stenosis and calcification of the LAD and a 75% stenosis of the left circumflex artery (Figure 1). At the time of surgery, following the institution of cardiopulmonary bypass and antegrade cardioplegic arrest, the LAD was found to be diffusely thickened and heavily calcified such that it was difficult to determine the optimal anastomatic site. In view of this adverse anatomy, an OCT catheter (Fast View, Terumo Inc., Tokyo, Japan) was placed on the LAD at four possible anastomatic sites on the LAD. The characteristics of the artery at each site was evaluated by a cardiologist who reviewed each OCT image

Right atrial thrombus entrapped in a Chiari's network

A 35-year-old male with a history of bilateral lower extremity deep vein thrombosis and a pulmonary embolus was found on transthoracic echocardiography to have a 4 × 2.5-cm floating thrombus in the right atrium (RA). Enhanced computed tomography revealed that the RA thrombus straddled a patent foramen ovale (PFO) and was associated with bilateral pulmonary emboli (Figure 1, Panel A). The patient was taken to the operating room and placed on cardiopulmonary bypass. The RA was opened after cardioplegic arrest and an RA thrombus was found at the PFO (Figure 1, Panel B) and was entrapped in a Chiaris network (Figure 1, Panel C). The thrombus

Aortic valve replacement with essential thrombocythemia

Cardiac surgery in patients with essential thrombocythemia carries the risks of both thrombotic events and a bleeding tendency. We report the case of a 75-year-old man with essential thrombocythemia who underwent successful surgical aortic valve replacement after his platelet count was controlled with plateletpheresis 3 times before surgery.