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OBJECTIVES An ascending aortic aneurysm with aortic valve regurgitation (AR) may be treated by sinutubular junction remodelling (STJR) with aortic cusp repair if the root diameter is preserved. We analysed the outcome of STJR with cusp repair. METHODS Between 1995 and 2010, 1094 patients underwent valve-preserving surgery. Of these, 560 individuals with root replacement, 128 patients with acute aortic dissection and 262 patients with preoperative AR ≤ II were excluded. The remaining 144 patients (mean age 56.0 ± 17.0 years, 103 males) underwent STJR ± cusp repair for ascending aortic aneurysm and AR ≥ III. In all, sinus dimensions were preserved according to the following criteria: maximum diameter ≤42 mm in bicuspid aortic valve (BAV, n = 59) and unicuspid aortic valve (UAV, n = 27), and ≤45 mm in tricuspid aortic valves (TAV, n = 58). In BAV, right–left (n = 52) and right-non-coronary (n = 7) cusp fusions were seen. To evaluate the influence of valve morphology, patients were divided into two groups: TAV and non-TAV. The patients with non-TAV were younger (P < 0.01) and had less concomitant cardiac surgery (P < 0.01). The mean follow-up was 25.9 ± 22.0 months. RESULTS Early mortality was 2.1% (n = 3). The causes of death were cardiac (n = 1), respiratory (n = 1) and mesenteric ischaemia (n = 1). Higher age was the predictor of early mortality by multivariate analysis (P = 0.04, hazard ratio 13.2). Overall 5-year survival was 93.9 ± 2.9% (TAV, 82.8 ± 10.2%; non-TAV, 98.5 ± 1.5%; P = 0.02). Causes of late death were cardiac (n = 1), respiratory (n = 1) and carcinoma (n = 1). Freedom from recurrent AR ≥ III at 5 years was 80.1 ± 7.7% (TAV, 97.0 ± 3.0%; non-TAV, 73.4 ± 8.7%; P = 0.02). By multivariate analysis, only aortoventricular junction (AVJ) > 28 mm (P < 0.01, hazard ratio 9.7) was a predictor of recurrent AR. Freedom from reoperation at 5 years was 81.9 ± 7.8% (TAV, 97.0 ± 3.0%; non-TAV, 76.6 ± 8.8%; P < 0.05). The causes of reoperation (five re-aortic valve repairs and four valve replacements) were dehiscence of pericardial patch (n = 7) and recurrent cusp prolapse (n = 2). By multivariate analysis, only AVJ > 28 mm was a significant predictor for reoperation (P < 0.01, hazard ratio 11.6). CONCLUSIONS STJR with cusp repair is a useful technique in patients with an ascending aortic aneurysm and relevant AR. Although the dilated AVJ is a risk of recurrent AR and reoperation, concomitant cusp repair is associated with an acceptable mid-term outcome. [ABSTRACT FROM AUTHOR]

Background: Destructive aortic valve endocarditis causes the development of left ventricular–aortic discontinuity. Our experience of aortic root replacement in patients with the left ventricular–aortic discontinuity is presented. Methods: Between 1999 and 2006, 8 patients (7 men, 1 woman) with left ventricular–aortic discontinuity underwent aortic root replacement in our institute. Their mean age was 56 years. Six patients were in New York Heart Association functional class III or higher. Four patients were diagnosed to have native valve endocarditis, and 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2 patients, aortic root replacements in 2). Radical débridement of the aortic root abscess was performed in all patients, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 2 patients. Fibrin glue saturated with antibiotics was applied into the cavity in 5 patients. Aortic root replacement was achieved with pulmonary autograft (Ross procedure) in 4 patients and stentless aortic root xenograft in 3. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary fashion. Results: No patients died during hospitalization or follow-up. Freedom from major adverse cardiac events was noted in 67% of the patients at 5 years. Conclusions: An excellent outcome can be achieved by radical exclusion of abscess in the cavity, followed by root replacement with viable pulmonary autograft or flexible stentless aortic root xenograft in patients with left ventricular–aortic discontinuity. [Copyright &y& Elsevier]

Abstract: Background: Total arch replacement necessitating deep hypothermia with circulatory arrest has a greater effect on pulmonary function than other cardiac surgery using cardiopulmonary bypass (CPB). Since April 2004, 100mg of sivelestat sodium hydrate was administrated by bolus injection into pulp circuit at the initiation of CPB in every case performed total arch replacement. We investigated the hypothesis that prophylactic use of the drug attenuates post-pump pulmonary dysfunction. Methods: A retrospective analysis of 120 consecutive patients who underwent total arch replacement from August 2001 to December 2006 was conducted. Patients were divided into two groups according to the date of surgery, April 2004, when we started sivelestat administration. Group A (n =60), operated after April 2004, was administrated sivelestat at the initiation of CPB. Group B (n =60), before April 2004, was not administrated. Time courses of hemodynamic variables were evaluated until 24h after surgery and those of respiratory variables and inflammatory markers until 48h after surgery. Results: There were no significant differences in patient age, sex, prevalence of chronic obstructive lung disease, preoperative lung function, time of operation and CPB, minimum temperature, and aprotinin usage. Hospital mortality occurred in two patients in the group B (3.3%) and no patient in group A (0%). Postoperative hemodynamic variables were not different between the two groups. Respiratory index, oxygenation index were significantly better in patients pretreated with sivelestat (respiratory index; p <0.001, oxygenation index; p <0.001, respectively). CRP was significantly lower in patients pretreated with sivelestat (p =0.022). Except for patients who required tracheostomy or re-exploration for bleeding, patients pretreated with sivelestat were extubated significantly shorter (group A: 12.6±10.8h, group B: 25.5±12.9h, p =0.033). No patient with postoperative respiratory failure requiring tracheostomy was noted in sivelestat group. Conclusion: Prophylactic administration of sivelestat at the initiation of CPB results in better postoperative pulmonary function, leading to earlier extubation time. Our study suggests that sivelestat was effective in facilitating postoperative respiratory management in total arch replacement. [Copyright &y& Elsevier]

An 82-year-old woman with a history of bladder cancer presented with dyspnea and loss of consciousness. Contrast-enhanced computed tomography revealed pulmonary embolism, and emergency thrombus aspiration therapy was performed, but the thrombus was not aspirated. Echocardiography showed mobile masses in the heart and a right-to-left shunt due to a patent foramen ovale (PFO). Magnetic resonance imaging showed multiple cerebral infarctions. Surgical thrombectomy and PFO closure were performed, and the patient was diagnosed with intracardiac metastasis of bladder cancer based on intraoperative histopathology. This is a rare case of concomitant pulmonary and cerebral tumor embolism and intracardiac metastasis from bladder cancer.