Tatsuhiko Kudo

The tricuspid pouch in endocardial cushion defect

Summary A tricuspid pouch was found in 15 out of 118 patients with ECD diagnosed either clinically by left ventriculography or at autopsy. The incidence demonstrated clinically with left ventriculography was 12 per cent; at autopsy, 18 per cent. The pouch is found exclusively in Grade II of ECD. Therefore, presence of the pouch in the lateral view of a left ventriculogram strongly indicates the possibility of Grade II malformation. The pouch resembles membranous septal aneurysm in its etiology and appearance in left ventriculograms. However, in the majority of cases, it was found that the former protrudes toward the inflow portion while the latter protrudes toward the outflow portion of the right ventricle.

Report of Simultaneous Off-Pump CABG and Modified Mastectomy

Abstract  The patient was a 75‐year‐old female who had received medical treatment for effort angina. Recently, she noticed a left breast tumor, which was diagnosed as breast cancer with axillary lymph node swelling. Coronary angiography performed prior to the surgery for the breast cancer showed 90% stenosis in segment 6 of the left anterior descending artery (LAD). Coronary intervention was not possible due to anatomical reasons, so she was admitted for simultaneous surgery for the breast cancer and angina. The chest was opened through a median sternotomy and the full‐skeletonized right internal thoracic artery was grafted on the LAD without cardiopulmonary bypass. A transverse elliptical incision was made after the median sternotomy was closed, and the breast tumor and lymph nodes around the subclavian and axillary vessels were completely dissected. Even in the case of multiple vessel coronary disease, simultaneous surgery may be possible, but indications should be carefully assessed considering the cardiac function and general condition of the patient.

Evaluation of coagulant activity after mechanical heart valve replacement

Long-term oral anticoagulant therapy is required for recipients of mechanical heart valves. In our hospital, the international normalized ratio of prothrombin time (PT-INR) has been set in the range 1.5–2.5 since October 2001. To evaluate whether coagulant activity is fully suppressed by this target range, coagulant activity was evaluated by measuring thrombin–antithrombin III complex (TAT) levels and valve-related complications were investigated retrospectively. Two hundred twenty-three patients who underwent mechanical valve replacement were enrolled in this study. PT-INR and TAT were measured at our outpatient clinic in March 2005 and valve-related complications since October 2001, when we started to control PT-INR in the range 1.5–2.5, were investigated. Under adequate warfarin control, there was no significant correlation between PT-INR and TAT, however nine patients who exhibited a PT-INR of less than 2.0 had high levels of TAT. And in atrial fibrillation (AF) patients after mitral valve replacement (MVR), the level of TAT was significantly high compared with sinus rhythm patients after atrial valve replacement. Valve-related complications were bleeding events at 2.75% per patient year and thromboembolism at 0.32% per patient year. Attention to complications of thromboembolism is necessary when the PT-INR is less than 2.0, especially in AF patients after MVR and in those with a thrombotic past history or high levels of TAT. The monitoring of TAT is useful in detecting potential coagulation factors and to determine the therapeutic range of warfarin that can normalize coagulant activity.

Cardiac pseudoaneurysm caused by mitral ring calcification

A case of left ventricular pseudoaneurysm caused by mitral ring calcification (MRC) in a 71-year-old woman is reported. MRC was initially detected by two-dimensional echocardiography. Two months later, rupture of the posterior wall and pseudoaneurysm formation were diagnosed. Mitral value replacement and reconstructive surgery of the myocardial wall were performed. The patient died 46 days after the operation. At autopsy, there was no histopathological evidence of myocardial infarction, infective endocarditis, or other conditions affecting the cardiac endomyocardium. Pseudoaneurysm apparently resulted from left atrial and ventricular tears caused by MRC.