Tsuyoshi Hachimaru

Influence of procedural differences on mitral valve configuration after surgical repair for functional mitral regurgitation: in which direction should the papillary muscle be relocated?

BackgroundAfter restrictive mitral annuloplasty (RMAP) for functional mitral regurgitation (MR), the MR frequently recurs. Papillary muscle relocation (PMR) should reduce the recurrence rate. We assessed the influence of procedural differences in PMR on the postoperative mitral valve configuration.MethodsThirty-nine patients who underwent mitral valve repair for functional MR were enrolled. In limited tethering cases, RMAP alone was performed (RMAP group; n = 23). In severe tethering cases, in addition to RMAP, bilateral papillary muscles were relocated in the direction of the posterior annulus (posterior PMR group; n = 10) or anterior annulus (anterior PMR group; n = 6). We performed pre- and postoperative transthoracic echocardiographic studies, introducing a new index, mitral inflow angle (MIA), to assess the diastolic mitral leaflet excursion. MIA was measured as the angle between the mitral annular plane and the bisector of the anterior and posterior leaflets.ResultsPostoperative MR grade was significantly reduced in each group (P < 0.001). Follow-up echocardiography showed recurrent MR in 13% of the patients in RMAP group. In contrast, no recurrent MR was observed in either the anterior PMR or the posterior PMR group. After surgery, MIA was significantly reduced in both the RMAP group (P < 0.01) and the posterior PMR group (P < 0.001), but was preserved in the anterior PMR group (NS). None of the postoperative variables showed any significant difference between the early and late postoperative phases.ConclusionsIn the surgical treatment of functional MR, a PMR procedure in addition to RMAP was effective in reducing systolic MR. However, mitral valve opening assessed by MIA was restricted even after RMAP alone. The restriction was severely augmented after additional posterior PMR, but was attenuated after additional anterior PMR. The papillary muscle should be relocated in the direction of the anterior annulus to preserve the diastolic opening of the mitral valve.

The Roles of Natriuretic Peptides in Pericardial Fluid in Patients with Heart Failure

It is well known that the plasma concentrations of atrial and brain natriuretic peptides, as cardiac hormones, are elevated in heart failure.

Easy and Safe Total Debranching of Arch Aneurysms Using Axilloaxillary Arterial Bypass

Techniques used in hybrid repair of proximal aortic arch diseases are associated with perioperative complications such as cerebrovascular emboli. We present an easy and safe technique of total debranching thoracic endovascular aortic repair for arch diseases using axilloaxillary arterial bypass. The placement of the axilloaxillary arterial bypass enables perfusion of the brachiocephalic artery even when the artery is clamped. After reconstruction of the brachiocephalic artery and the left common carotid artery, the left subclavian artery is proximally ligated, and it is perfused through the bypass. This procedure is simple, safe, and useful for the prevention of neurologic complications.

Management of Right Gastroepiploic Arterial Coronary Grafts in Subsequent Abdominal Surgeries

BACKGROUND The right gastroepiploic artery (GEA) is utilized as an excellent in situ arterial graft conduit to right coronary artery territory for coronary artery bypass grafting (CABG). However, there remain great concerns regarding the management of patients with a patent in situ GEA during abdominal surgery following CABG. METHODS From 1995 to 2016, GEA was used for CABG in 278 patients at our institution. Of the patients, 14 abdominal surgeries were performed for subsequent abdominal diseases in 11 patients with a patent in situ GEA for CABG. We investigated the results of the surgeries and how to manage the GEAs in abdominal surgery. RESULTS Laparotomy was required for gastric cancer in 3 patients, pancreatic cancer in 3, hepatic cancer in 2, cholangiocarcinoma in 1, duodenal papillary head cancer in 1, and cholecystitis in 1; multiple abdominal surgeries were needed in 2 patients for cancer recurrence and ileus. The intraabdominal adhesions around the GEAs were minimal in all patients. No graft injury occurred at the time of opening of the abdomen, and the planned procedures were completed without any circulatory problems. In 3 patients undergoing pancreaticoduodenectomy, intraabdominal off-pump rerouting of the GEA with a short saphenous vein was necessary for en bloc resection of the cancers and lymph nodes. There was neither operative mortality nor graft-related cardiac event except for 1 due to multiple organ failure. CONCLUSIONS Although intraabdominal rerouting of GEA is necessary for pancreaticoduodenectomy, abdominal surgery can be safely performed in patients with a patent in situ GEA coronary graft.

Excision of thoracic vertebral chondrosarcoma after spinal decompression

A 44-year-old man presented with an abnormal chest shadow. Computed tomography-guided biopsy showed a chondral tumor of the thoracic vertebrae. Five years later, he developed a walking disorder, left leg numbness, and a vesicorectal disorder. Emergency orthopedic spinal decompression was performed. Eight months later, the residual tumor had become larger and was adjacent to the aorta. Prior to thoracotomy, an intraaortic stent was inserted. The 4th and 5th ribs were invaded by the tumor. The entire tumor and chest wall were excised with the aortic adventitia. The tumor was diagnosed as a low-grade chondrosarcoma of the thoracic vertebrae.

Antineutrophil Cytoplasmic Antibody—Associated Multiple Giant Saccular Aortic Aneurysms

We describe a very rare case of a 67-year-old man with multiple saccular aortic aneurysms throughout the entire aorta due to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The patient underwent staged aortic surgical procedures, including stent-graft insertion for a left iliac artery aneurysm, thoracic endovascular aortic repair for a descending aortic aneurysm, and total replacement of the ascending aorta and aortic arch with the use of high-dose steroids to control inflammation. The histologic findings demonstrated that the damage to the vasa vasorum of the adventitia resulting from AAV caused ischemia of the media, resulting in the formation of saccular aneurysmal changes.

Detection of Internal Thoracic Artery Dissection at Coronary Anastomosis Using Intraoperative 15-MHz High-Frequency Epicardial Ultrasound

A 66-year-old man with a history of diabetes mellitus presented with angina pectoris with 3-vessel disease, and he underwent off-pump coronary artery bypass grafting via median sternotomy. After performing bypass grafting of the left internal thoracic artery to the left anterior descending artery, the appearance of anastomosis configuration appeared to be acceptable. However, transit time flow measurement (TTFM) showed that the mean graft flow was 10 mL/min, which was less than expected despite an acceptable flow curve with a diastolic flow pattern, a pulsatility index (index of resistance) of 2.0, and diastolic filling (proportion of diastole with coronary flow) of 65% (Figure 1). In addition to TTFM, the …