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Patients with total circumferential mitral annular calcification (MAC) extending into the intervalvular fibrous body and aortic annulus have a high risk of cardiac surgery, which remains a technical challenge for surgeons. Our technique for MAC is characterized as simple supra-mitral annular prosthesis insertion after minimum debridement of calcification ("half-and-half technique"). To date, our technique has been applied in only simple MAC cases and has good results. Herein, we report successful two cases of total circumferential MAC, extending into the intervalvular fibrous body and aortic annulus that were treated by a simple double valve replacement with application of our "half-and-half technique".

A 72-year-old man presented with worsening dyspnea on effort. He underwent right pneumonectomy 40 years ago, then mitral valve replacement through a right thoracotomy 8 years ago with repeat surgery to repair a periprosthetic valve leak; the mediastinum was displaced to the right, and the heart was rotated counterclockwise. Transthoracic echocardiography showed periprosthetic valve leak recurrence near the left atrial appendage. We repaired the periprosthetic valve leak through a median sternotomy. Transecting the main pulmonary artery allowed us to widely open the cranial-sided left atrium. We obtained good exposure of the mitral valve, and repaired the periprosthetic valve leak using pledgeted sutures and a pericardial patch., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Atrial functional mitral regurgitation (MR) has been recently described in patients with chronic atrial fibrillation (AF). However, the results of surgical mitral valve (MV) repair for this type of MR have not been comprehensively reported. Our study aimed to address this deficiency., Methods: We retrospectively studied 10 chronic AF patients who underwent MV repair for atrial functional MR with normal left ventricular dimension and preserved left ventricular systolic function. All patients had chronic heart failure (HF) symptoms and at least one prior admission for HF complicated by severe MR., Results: Ring annuloplasty was performed in all patients; the median ring size was 26 mm (range, 26-30 mm). Concomitant tricuspid valve repair was undertaken in all patients. Preoperatively, left atrial (LA) diameter on the parasternal long-axis view, LA volume index and mitral annular diameter were 52 ± 9 mm, 72 ± 26 ml/m(2) and 33 ± 4 mm, respectively. There was no mortality and no re-admission due to HF during follow-up (range, 10-52 months). MR at the most recent examination was mild or improved in degree in all patients. The LA volume index decreased from the preoperative period, measuring 48 ± 17 ml/m(2) at the most recent period (P = 0.03). The New York Heart Association functional class dramatically improved from the preoperative period to the most recent period (from 3.0 ± 0.7 to 1.2 ± 0.4, P < 0.0001)., Conclusions: Our results suggest that MV repair leads to reductions in MR, LA size and HF symptoms, and that it may prevent future HF events in patients with atrial functional MR., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity., Methods: One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test., Results: Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637)., Conclusions: The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

Objectives: Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes., Methods: In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery., Results: Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups., Conclusions: In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

Purpose: Few recent studies have examined the long-term outcomes after aortic valve replacement (AVR), and independent predictors for long-term survival and valve-related mortality have not been elucidated., Methods: From January 1993 to December 2009, 132 elderly patients (≥70 years old) with aortic stenosis underwent AVR in our hospital. The patients comprised 61 men and71 women with a mean age of 76.1 ± 3.7 years. Patients with acute or old myocardial infarction, mitral valve disease, and re-do surgery were not included in this study. Risk factors for late valve-related mortality were examined., Results: The 5-year freedom from valve-related mortality rate was 89.6%. The following significant independent risk factors for late valve-related mortality were identified:increase in the preoperative left ventricular mass index (hazard ratio, 1.10 [per 10 g/m(2)];p = 0.040); lack of sinus rhythm (hazard ratio, 7.11; p = 0.005); peak transvalvular pressure gradient of <60 mmHg (hazard ratio, 7.48; p = 0.008)., Conclusion: In the elderly, AVR should be performed at an early stage of aortic stenosis, before an increase in the left ventricular mass index has occured, and while the heart rhythm is in sinus rhythm and the peak transvalvular pressure gradient is high.

Three patients with poor left ventricular function (left ventricular ejection fraction <30 %) developed postoperative atrial tachyarrhythmia in intensive care. Case 1 was a 64-year-old man who underwent a modified Bentall procedure and mitral valve annuloplasty. Case 2 was a 63-year-old woman who underwent quintuple coronary artery bypass grafting. Case 3 was a 65-year-old man who underwent mitral valve replacement. Preoperative intra-aortic balloon pumping was required in Cases 2 and 3. Excellent heart rate control with no hemodynamic deterioration was achieved in all three cases by very-low-dose continuous drip infusion of landiolol hydrochloride (2-5 μg/kg/min). Very-low-dose continuous drip infusion of landiolol hydrochloride is a safe and useful alternative for the control of perioperative atrial tachyarrhythmias in patients with poor left ventricular function.

The goal of this prospective study was to examine the effects of landiolol hydrochloride on prevention of atrial fibrillation and on hemodynamics in the acute postoperative phase after heart valve surgery. The subjects were 60 patients who underwent valve surgery at our hospital from April 2008 to July 2010. The patients were randomly divided into two groups: the landiolol group (30 patients) and the control (no landiolol) group (30 patients). In the landiolol group, continuous intravenous landiolol was initiated immediately on admission to the intensive care unit at a dose of 10 µg/kg/ minute. Occurrence of atrial fibrillation was compared between the groups over an observation period of 72 hours after surgery. Atrial fibrillation occurred in 6 patients (20%) in the landiolol group and 16 (53.3%) in the control group during the observation period. Landiolol hydrochloride significantly reduced the occurrence of atrial fibrillation in the acute postoperative phase after heart valve surgery. Heart rate was significantly decreased by landiolol, but aggravation of hemodynamics was not observed. These results suggest that landiolol is a useful drug for prevention of atrial fibrillation after valve surgery.

Background and Aim of the Study: Left ventricular (LV) rupture is a rare but lethal complication after mitral valve replacement (MVR). Hence, the occurrence of LV rupture after MVR and the outcome of resuscitation was assessed., Methods: Between January 1991 and June 2005, a total of 258 patients underwent MVR at the authors' institution. Thirteen preoperative factors and 13 surgical factors were analyzed to assess the incidence of LV rupture after MVR., Results: Among the patients, there were six cases of LV rupture (2.3%). Age >69 years (p = 0.0174), hemodialysis (p = 0.0119), echocardiographic end-diastolic left ventricular diameter (Dd) <50 mm (p = 0.0104), resection of the basal chorda of the posterior leaflet (p = 0.0086), mitral annular reconstruction (p = 0.009), and additional left atrial plication (p = 0.0269) were each considered as significant risk factors for LV rupture following MVR. All ruptures were type III. There were two hospital deaths (mortality 33%). At more than one year after surgery, all surviving patients were in reasonable health., Conclusion: Older age, hemodialysis, and Dd <50 mm are significant risk factors for LV rupture after MVR. Preservation of the basal chordae of the posterior leaflet was important to prevent LV rupture, while endocardial patch repair with elective intraaortic balloon pumping was suggested as an effective treatment for type III rupture.