Total root remodelling by the Sleeve technique for aortic regurgitation in patients with repaired tetralogy of Fallot

We report the case of a 15-year-old male patient who had developed aortic regurgitation primarily because of aortic annulus dilatation late after definitive repair of tetralogy of Fallot. Valsalva sinus dilatation was not remarkable enough for root replacement. For the purpose of total root remodelling, the Sleeve procedure was employed. This procedure not only reduced the root diameters but also augmented commissure heights. With concomitant non-coronary cusp plication, aortic regurgitation was effectively controlled. Thus, the Sleeve technique may be a preferable option for patients who develop aortic regurgitation, due to dilatation of the annulus or sinotubular junction without significant dilatation of the sinus of Valsalva, after congenital heart surgery

Risk factors of recurrent tricuspid regurgitation after valve repair with three-dimensional ring

Objective: The purpose of this study was to investigate the results of tricuspid valve (TV) repair with three-dimensional ring (3DR) and risk factors of recurrent tricuspid regurgitation (TR).Methods: We retrospectively investigated 171 patients who underwent TV repair with a 3DR for TR from 2007 to 2016 at our institution. The patients were divided into the non-Recurrence group (<2+ TR) and Recurrence group (≥2+ TR), and compared to identify the cause of recurrent TR. The mean follow-up period was 58±35 months.Results: The preoperative TR grade was 3.0±0.8. A total of 22 patients had at least ≥2+ TR in the follow-up period. Freedom from ≥2+ TR and re-operation at 5 years were 83.6±3.3% and 97.9±2.1%. Comparison of the non-Recurrence and Recurrence groups revealed significant differences in the preoperative TR grade (2.9±0.8 and 3.4±0.6, p=0.008), proportion of the patients with left ventricular ejection fraction (LVEF) <40% (9% and 32%, p=0.003) and right ventricular end-systolic dimension (RVDs, 22.8±7.1 mm and 31.1±12.3 mm, P=0.001). In the multivariate analysis, LVEF <40% (hazard ratio: 12.65, 95% confidence interval: 2.66–60.18; p=0.002) and RVDs (hazard ratio: 1.08, 95% confidence interval: 1.02–1.14; p=0.02) were identified as risk factors for recurrent TR.Conclusion: Our results of TV repair with 3DR were of satisfactory. However, patients with preoperative lower LVEF and larger RVDs were identified at risk of recurrent TR. This result suggests the limitation to use of 3DR alone for TV repair and need for additional procedure

Energetic Advantage of Phosphodiesterase III Inhibitors in the Failed Heart after Global Ischemia

We evaluated the ventricular mechanical effects of PhosphodiesteraseIII (PDEIII) inhibitors in the failed heart after global ischemia induced by ventricular fibrillation (VF) using the left ventricular pressure-volume relationship (PVR). In 14 anesthetized open-chest dogs, left ventricular PVR was measured using a conductance catheter. Under administration of milrinone (MIL, n=7) and olprinone (OLP, n=7), the slopes of the LV end-systolic pressure-volume (Emax), arterial end-systolic pressure-stroke volume relations (Ea), ventriculoarterial coupling (Ea/Emax) and preload recruitable stroke work (PRSW) were obtained to evaluate changes in LV performance. The duration of VF was 1 min without cardiopulmonary bypass (CPB). OLP and MIL significantly increased the Emax and PRSW values in the failed heart after VF, and there was no dose-effect relationship at MIL doses of 0.25 to 0.75ﾎｼg/kg/min or at OLP doses of 0.1 to 0.3ﾎｼg/kg/min. The Ea/Emax value after VF was significantly lower in the presence of OLP or MIL than in the absence of these drugs (-45.3% with OLP and -46.5% with MIL). The results indicate that in the heart after transient global ischemia, both OLP and MIL improve hemodynamic and mechanical states in terms of ventriculoarterial coupling

Comparison of Exercise Echocardiography in Patients with 18mm ATS-AP Aortic Prosthesis

There have been various arguments concerning the patient-prosthesis mismatch (PPM) after aortic valve replacement (AVR) for small valves. The objective of this study was to evaluate the postoperative hemodynamics in patients. Methods: The subjects were 6 patients [6 females aged 64 (17~74) years, with a median body surface area (BSA) of 1.37 (1.29~1.51) m2] who underwent AVR at our facility using the 18-mm ATS-AP and tolerated exercise loading. We estimated pressure gradient(PG) ,ejection fraction(EF), left ventricular mass Index(LVMI)at pre-operation and post-operation. Exercise echocardiography on an ergometer was performed before and 29.0 ± 14.4 months after surgery. We estimated PG and effective orifice area(EOAI) at rest and at exercise. We compared echo data between pre-operation and post-operation, between at rest and at exercise. Results: The effective orifice area index(EOAI) at rest was 0.92(0.75~1.06) cm2/m2. There was a significant change in the LVMI between pre-operation and post-operation[158.5(104.0~222.2) g/m2 versus 102.4(92.3~146.4) g/m2; P 0.05] and mean PG[11.0(6.6~16) mmHg versus 14.0(6.3~16) mmHg; P > 0.05], on maximal exercise. Conclusion: In patients whose BSA were 1.37(1.29~1.51) m2,the 18-mm ATS-AP was suggested to be a prosthetic valve that improves myocardial remodeling and provides stable hemodynamics even during exercise

Clinical and microbiological characteristics and challenges in diagnosing infected aneurysm: a retrospective observational study from a single center in Japan

Background: It is challenging to diagnose infected aneurysm in the early phase. This study aimed to describe the clinical and microbiological characteristics of infected aneurysm, and to elucidate the difculties in diagnosing the disease.Methods: Forty-one cases of infected aneurysm were diagnosed in Nagasaki University Hospital from 2005 to 2019. Information on clinical and microbiological characteristics, radiological fndings, duration of onset, and type of initial computed tomography (CT) imaging conditions were collected. Factors related to diagnostic delay were analyzed by Fisher’s exact test for categorical variables or by the Wilcoxon rank-sum test for continuous variables.Results: Pathogens were identifed in 34 of 41 cases; the pathogens were Gram-positive cocci in 16 cases, Gram-negative rods in 13 cases, and others in fve cases. Clinical characteristics did not difer in accordance with the identifed bacteria. At the time of admission, 16 patients were given diferent initial diagnoses, of which acute pyelonephritis (n=5) was the most frequent. Compared with the 22 patients with an accurate initial diagnosis, the 19 initially misdiagnosed patients were more likely to have been examined by plain CT. The sensitivities of plain CT and contrastenhanced CT were 38.1% and 80.0%, respectively.Conclusions: In cases of infected aneurysm, diagnostic delay is attributed to non-specifc symptoms and the low sensitivity of plain CT. Clinical characteristics of infected aneurysm mimic various diseases. Contrast-enhanced CT should be considered if infected aneurysm is suspected

Operative Outcome of Cardiac Surgery in Patients with Liver Cirrhosis

Introduction: A retrospective study was performed to investigate the relationship between the severity of liver cirrhosis and the outcome of cardiac surgery. Methods and Results: Twenty-one patients with liver cirrhosis underwent cardiac surgery in our institution. According to the Child-Pugh classification, 13 patients were in class A, 7 in class B, and 1 in class C. Coronary artery bypass grafting was performed in 7 patients, surgery for valvular disease in 10 and other procedures in 4. Major postoperative complications occurred in 8%, 29%, and 100% for Child-Pugh class A, B, and C, respectively. Preoperative hemoglobin level was significantly lower in the patients with postoperative complications. None of 4 patients underwent coronary revascularization using off-pump procedure or mini-pump system experienced major complication. The operative mortality was 0%, 14%, and 0% for Child-Pugh class A, B, and C, respectively. Conclusions: Although the overall mortality rate in patients with liver cirrhosis was acceptable in our study, the incidence of severe complications, such as prolonged ventilation, mediastinitis and irreversible hepatic insufficiency was problematic in Child-Pugh class B and class C patients. Application of less invasive cardiac surgery, such as mini-pump system or off-pump procedure will improve the operative outcome in such patient group.長崎大学学位論文 学位記番号:博（医）甲第1,272号学位授与年月日:平成20年7月16

Surgical experience with chronic constrictive pericarditis

Objective: Constrictive pericarditis is a disease characterized by marked thickening of the pericardium which causes restriction of diastolic cardiac function. The purpose of this report is to review the outcome of pericardiectomy for constrictive pericarditis and to discuss its problems. Methods: Sixteen consecutive patients who underwent pericardiectomy for constrictive pericarditis in our institution between March 2000 and June 2011 were reviewed. All patients underwent decortication including at least the anterior surface from the right atrium to the left phrenic nerve and the diaphragmatic surface of the heart. The epicardium was concomitantly resectioned because it was usually sclerotic and constrictive. Results: Postoperatively, mean central venous pressure decreased to 8.8 ± 3.1 mmHg and was significantly lower than the preoperative value 15.3 ± 3.7 mmHg (p < 0.001). The mean postoperative duration of hospitalization was 25.6 ± 13.5 days. There were 2 in-hospital deaths and early mortality rate was 12.5 %; however, excluding hospital deaths, there were no significant postoperative complications and all survivors recovered and maintained good cardiac function during the mean follow-up period of 3.7 ± 2.8 years. Conclusion: For an acceptable outcome, surgical intervention should be performed at an appropriate time and the pericardiectomy should have proper scope and depth to prevent irreversible changes in the heart, liver, and other organs

Quality of life following aortic valve replacement in octogenarians

【Purpose】We aimed to evaluate the outcomes of and the quality of life (QOL) after conventional aortic valve replacement (AVR) amongst octogenarians.【Methods】We enrolled 48 patients aged ≥80 years who underwent conventional aortic valve replacement between May 1999 and November 2012. Patient conditions were assessed before surgery, at 6 and 12 months after surgery, and during the late period regarding the need for nursing care, degree of independent living, and living willingness.【Results】The follow-up rate was 100% with 45.6 ± 41.3 months follow-up. Two patients (4%) died during hospitalization and 11 (23%) died during the follow-up period. The 1-, 5-, and 10-year survival rates were 84.9, 76.9, and 39.6%, respectively. During the late period, of 35 surviving patients, 31 (88%) were living at home. The degree of independent living score decreased after surgery. However, scores of the need for nursing care and living willingness remained preoperative level.【Conclusions】QOL following conventional aortic valve replacement for elderly patients aged ≥80 years who showed independence in activities of daily living (ADL) before surgery were satisfactory. Therefore, aortic valve replacement could be a viable option for elderly patients aged ≥80 years after accounting for preoperative ADL levels