Takehiro Kubota

Anomalous origin of the left coronary artery from the pulmonary artery in an adult: tubular reconstruction of the left main coronary artery under coronary perfusion.

Abstract A 38‐year‐old female with anomalous origin of the left coronary artery (LCA) from pulmonary artery was surgically corrected by tubular reconstruction of the left main coronary artery (LMCA) using the pulmonary artery wall, and this repair was performed under beating heart. Thus, the pulmonary artery was divided above the orifice level and just above the pulmonary valve, and the commissure between nonfacing and left side sinuses was dissected away from the pulmonary artery wall to obtain lateral flaps. The pulmonary artery defect was reconstructed with a roll using an autologous pericardial patch, while the detached commissure was suspended on the pericardial patch. The long tube constructed using pulmonary artery tissue was anastomosed to the anterior aspect of the ascending aorta. These procedures were performed under beating heart simply by clamping the LMCA, since the preoperative myocardial contrast echocardiography confirmed the adequate coronary collateral flow from the right circulation. The postoperative course was uneventful, and a coronary artery angiogram demonstrated a widely patent LMCA. Our experience suggests that, in adult cases, this procedure could be performed without myocardial ischemia simply by clamping the LMCA because of well‐developed coronary collateral arteries. The safety of this technique could be confirmed by myocardial contrast echocardiography.

Long-term results of aortic valve regurgitation after repair of ruptured sinus of valsalva aneurysm

BACKGROUND We reviewed our 35-year-experience to investigate the determinants of long-term results of aortic valve regurgitation (AR) after surgical repair of ruptured sinus of Valsalva aneurysms (RSVA). METHODS Between 1963 and 1998, a total of 35 patients aged 7 to 64 years underwent surgery for RSVA. The aneurysms ruptured into the right ventricle (n = 24), right atrium (n = 10), and left atrium (n = 1). In all, 19 patients had VSD and 9 patients had AR. A combined approach through aortotomy and the involved chamber was used for 24 patients. Either direct (n = 19) or patch (n = 16) closure was used to close the rupture hole. The AR was graded on a scale of 0 to IV by angiographic or echographic evaluation. RESULTS There were no early deaths. Late death occurred in 1 patient, whose AR deteriorated to grade III 20 years later. Two patients (5.7%) required reoperations on the aortic valve, because grade III AR was noted 8 and 26 years after operation, respectively. Freedom from postoperative grade III AR or higher was 93% at 10 years and was 87% at 20 years. Late AR was associated with preoperative and early postoperative AR (p < 0.05) but not with the presence of VSD, location of the fistula, surgical approach, or type of repair (direct vs patch). Multivariate analysis indicated that early postoperative AR was the only independent variable. CONCLUSIONS Late AR necessitating reoperation still confers significant risk in the long-term follow-up after repair of RSVA. No particular risk factor of preoperative conditions and surgical methods was elucidated in this study, and postoperative AR at discharge from the hospital was the only factor determining the long-term results of AR.

Wavelet analysis of bileaflet mechanical valve sounds

It has been reported that asynchronous leaflet closure in a bileaflet mechanical valve causes a split in the valve closing sound. We have previously reported that the continuous wavelet transform (CWT) with the Morlet wavelet as modified by Ishikawa (the Morlet wavelet) is the most suitable method among the CWTs for detecting a split in the bileaflet mechanical valve sound because this method can detect the highest frequency signal among the CWT methods with higher time resolution. This is the first article which discusses the acoustic properties of five types of bileaflet valves using the Morlet CWT. Similar behavior of the valve sound split intervals with wide fluctuations over consecutive heartbeats was found to be the common finding for all the bileaflet valves. This result suggests that fluctuation of the split interval proves the normal movement of both leaflets without movement disturbance. The mean differences in the split interval between these bileaflet valves were statistically significant, and the wavelet coefficients of the CWT showed characteristic scalographic patterns, such as a teardrop shape or a triangle beneath the split. However, these two findings gave no valuable information for the diagnosis of bileaflet valve malfunction. A split in the valve closing sound with a fluctuating interval was the common finding in these five normally functioning bileaflet valves, and careful observation of the splits behavior may be a key to diagnosis of bileaflet valve malfunction.

Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect. Feasibility of transpulmonary approach.

BACKGROUND Minimally invasive techniques in congenital heart surgery have evolved steadily over the past few years, but documentation in the literature is rare. The majority of reported techniques involve thoracoscopic approach and partial sternotomy. We have employed a lower partial sternotomy as a minimal-access procedure for the closure of subarterial ventricular septal defect, for situation where this approach would be unsuitable for adequate exposure of the pulmonary artery. The purpose of this study is to demonstrate the feasibility and safety of this technique and report its superior cosmetic result. SUBJECTS AND METHODS Beginning in 1997, we began approaching the closure of subarterial ventricular septal defect through a lower sternal split incision using a 6 to 10 cm skin opening, associated with a reversed L incision at the left second intercostal space. A total of consecutive 12 patients (6 male and 6 female) have been operated on using this approach. The patients ranged in age from 6 to 21 years (mean, 12.8 +/- 5.0 years). The straight cannula with stylet was used for aortic cannulation. RESULTS There was no mortality or morbidity, except for late pericardial effusion in 4 cases. The durations of cardiopulmonary bypass and aortic cross-clamping ranged from 94 to 206 (mean, 131 +/- 33) minutes and from 40 to 122 (mean, 70 +/- 26) minutes, respectively. Ten of 12 patients were extubated in the operating room, and no patient required blood transfusion. The postoperative hospital stay ranged from 8 to 21 (mean, 13.4 +/- 4.2) days. No patient developed deterioration of aortic regurgitation or residual ventricular septal defect. CONCLUSIONS Our experience demonstrates that the lower partial sternotomy for the closure of subarterial ventricular septal defect is technically feasible and can be used with excellent cosmetic results and safety. Although experience is limited and follow-up is relatively short, this less invasive surgical technique may become a beneficial option for the management of subarterial ventricular septal defect.

Application of the reversed elephant trunk technique during total thoracoabdominal replacement in patients with Marfan's syndrome

Abstract The reversed elephant trunk operation has been applied in patients with extensive aortic involvement as a scheduled staged operation. We report application of the same technique in two patients with Marfans syndrome. The two patients underwent total replacement of the thoracoabdominal aorta for a DeBakey IIIb aortic dissection. The proximal end of the prosthetic graft was invaginated to facilitate future proximal operation. No complication related to the trunk had been observed during the follow‐up period. (J Card Surg 1998; 13:56–59)

Simplified Technique for Patch Augmentation and Chorda Reconstruction of Left Atrioventricular Valve in Complete Atrioventricular Septal Defect

Abstract Management of the left AV valve is the most crucial component of the repair of complete atrioventricular septal defect (cAVSD). A scarcity or deficiency of leaflet tissue may compromise satisfactory repair in a small number of patients with cAVSD, especially in patients with a normal karyotype. We describe the case of a 44‐day‐old baby who had cAVSD with severe left atrioventricular valve regurgitation due to dysplastic bridging leaflets. The repair was successfully performed by augmenting leaflet tissue and reconstructing the chorda using single patch. This technique could be one of the options in the repair of valves in order to avoid valve replacement in a small infant, although material of patch and reoperation need to be considered. (J Card Surg 2003;18:253‐256)

Off‐Pump Aortic Arch Repair Through a Median Sternotomy for Type B Interrupted Aortic Arch With Single Ventricle Physiology

Abstract  Background: The aortic arch repair for interrupted aortic arch (IAA) with the hypoplastic ascending aorta through a median sternotomy requires cardiopulmonary bypass (CPB), which is very invasive in neonates and complicates pulmonary artery banding (PAB) is staged repair. Methods: A 22‐day‐old neonate with a type B IAA having a functional single ventricle underwent arch repair and PAB through a median sternotomy without CPB. A partial occlusion clamp could be placed on the ascending aorta without cerebral malperfusion and the descending aorta could be directly anastomosed to the ascending aorta in an end‐to‐side fashion under stable circulatory condition. Thereafter, the tight PAB was performed with a circumference of 23mm without any difficulty. Results: The postoperative echocardiogram revealed no stenosis on the anastomotic site and the patient was discharged uneventfully. Conclusion: This approach is effective in neonates with IAA who require staged repair, and least invasive for them.