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We present a case of cardiac calcified amorphous tumor, a rare intracardiac non-neoplastic tumor, in a hemodialysis patient. A 72-year-old woman with no history of thromboembolic, malignant, or inflammatory disease presented with dyspnea. Echocardiography revealed a highly echoic, slightly mobile mass with an acoustic shadow originating from the mitral subvalvular apparatus, extending to the left ventricular outflow tract. She underwent surgical resection of the mass through the aortic valve, which was easily excised from the papillary muscle and chordae tendineae. Histopathologic examination revealed nodular calcium deposits on a background of amorphous degenerated fibrin material, consistent with calcified amorphous tumor., (© The Author(s) 2015.)

Adventitial cystic disease is a rare non-atherosclerotic vascular disease. We report a 36-year-old man with right intermittent claudication by adventitial cystic disease. computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid cystic mass compressing the right popliteal artery and causing severe stenosis of the lumen. Percutaneous aspiration was performed, which improved his symptoms. However, he complained of identical intermittent claudication two weeks later. Radiographic findings revealed that the cystic lesion had progressed rapidly. The cystic lesion was resected and the affected arterial segment was interposed. We consider that conventional surgical intervention remains the favored treatment option in the management of adventitial cystic disease.

Aims: The clinical outcome of severe acute myocarditis patients with cardiogenic shock who require circulatory support devices is not well known. We studied the survival and clinical courses of patients with fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation (ECMO) and compared them with those of patients with acute non-fulminant myocarditis., Methods and Results: Patients with acute myocarditis were divided into the following two groups. Fourteen patients who required ECMO for cardiogenic shock were defined as having fulminant myocarditis (F group), whereas 13 patients who had an acute onset of symptoms, but did not have compromised, were defined as having acute non-fulminant myocarditis (NF group). In the F group, 10 patients were weaned successfully from percutaneous ECMO. Therefore, the overall acute survival rate was 71%. Patients who were not weaned from ECMO showed smaller left ventricular end-diastolic and end-systolic dimensions, thicker left ventricular wall, and higher creatine phosphokinase MB isoform levels than those who were weaned from ECMO. When compared with patients in the NF group, the fractional shortening in the F group was more severely decreased in the acute phase [F: 10+/-4 vs. NF: 23+/-8% (mean+/-SD), P<0.001], but recovered in the chronic phase (F: 33+/-7 vs. NF: 34+/-6%). The prevalence of adverse clinical events in both groups was similar during the follow-up period of 50 months., Conclusion: In patients with fulminant myocarditis, percutaneous ECMO is a highly effective form of a haemodynamic support. Once a patient recovers from inflammatory myocardial damage, the subsequent clinical outcome is favourable, similar to that observed in patients with acute non-fulminant myocarditis.

Perioperative coronary vasospasm has been recognized as a possible cause of myocardial infarction or low output syndrome after open heart operations. A 57-year-old male suffered cardiogenic shock immediately after off-pump coronary artery bypass grafting surgery. Emergent angiography performed under intraaortic balloon pumping and percutaneous cardiopulmonary support revealed severe multivessel coronary vasospasm which was effectively treated with a high dose intracoronary administration of isosorbide dinitrate. Emergent angiography for patients with cardiogenic shock after open heart operation is feasible and effective for the diagnosis and treatment of perioperative coronary vasospasm.

Objectives: Left ventricular free wall rupture is a major complication after myocardial infarction. Simple gluing for a rupture site, without a cardiopulmonary bypass, has been reported useful., Methods: We experienced a left ventricular pseudoaneurysm, of 8 cm in size, emerging at a previous rupture site 1 year after gluing with TachoComb for an oozing-type rupture due to an acute anteroseptal myocardial infarction., Results: The pseudoaneurysm was successfully extirpated, under a cardiopulmonary bypass, with induction of ventricular fibrillation., Conclusions: Patients, after simple gluing for a left ventricular free wall rupture, should be carefully followed up regarding the occurrence of a pseudoaneurysm at the repair site.

Background: The purpose of this study was to evaluate morbidity and mortality after double valve replacement (DVR) and aortic valve replacement with mitral valve repair (AVR + MVP)., Methods: From 1977 to 2000, 379 patients underwent DVR (n = 299) or AVR + MVP (n = 80). Actuarial survival and freedom from reoperation were determined by the Kaplan-Meier method. Potential predictors of mortality and reoperation were entered into a Cox multiple regression model. Propensity score was introduced for the multivariable regression modeling for adjustment of a selection bias., Results: Survival 15 years after surgery was similar between the groups (DVR, 81% +/- 3%; AVR + MVP, 79% +/- 7%; p = 0.44). Freedom from thromboembolic event at 15 years was similar between the groups (p = 0.25). Freedom from mitral valve reoperation at 15 years was significantly better for the DVR group (54% +/- 5%) as compared with the AVR + MVP group (15% +/- 6%; p = 0.0006), primarily due to progression of mitral valve pathology and early structural deterioration of bioprosthetic aortic valve used for patients with AVR + MVP. After AVR + MVP, freedom from mitral reoperation at 15 years was 63% +/- 16% for nonrheumatic heart diseases, and 5% +/- 5% for rheumatic disease (p = 0.04)., Conclusions: Although both DVR and AVR + MVP provided excellent survival, DVR with mechanical valves should be the procedure of choice for the majority of patients because of lower incidence of valve failure and similar rate of thromboembolic complications compared with AVR + MVP. MVP should not be performed in patients with rheumatic disease because of higher incidence of late failure.

We treated a 68-year-old woman with warm-reactive type of autoimmune hemolytic anemia (AIHA) who underwent aortic valve replacement. In consideration of the different hemolytic mechanisms between cardiopulmonary bypass and warm-reactive AIHA, conventional surgical procedures could be performed after the discontinuation of steroid therapy.

Background: The maze procedure is an effective way to treat atrial fibrillation (AF) associated with mitral valve disease. In a last several years, cryoablation was substituted for atrial incision in many reports to simplify the maze procedure. However, there has been no comparative study to delineate the feasibility of the use of cryoablation., Methods and Results: We compared the early and intermediate-term results of the maze procedure including pulmonary venous isolation from the left atrium using cryoablation (CM) with our conventional (Kosakai) maze procedure (KM) including encircling incision around the orifices of pulmonary veins. One hundred and 10 pairs of patients were matched in the age, left atrial dimension >70 mm, duration of AF >0 years, previous cardiac surgery, mechanical valve implantation and concomitant aortic valve procedures. CM required significantly shorter cardiopulmonary bypass time (186+/-56 minute versus 214+/-47 minute, P=0.001) and aortic cross-clamp time (134+/-43 minute versus 144+/-37 minute, P=0.03) than KM with less chest tube drainage (590+/-353 mL versus 745+/-618 mL, P=0.02) for 12 hours after operation. The sinus rhythm restoration rate in CM group (85.4%) was comparable with KM group (86.4%) at discharge. In the late results, the actuarial freedom from recurrence of sustained AF at 3 years in CM group (97.7%) was not significantly (P=0.11) different from that in KM group (90.4%). The actuarial freedom from stroke at 3 years in CM group was 99.0%., Conclusion: The modification of the maze procedure including cryoablation for pulmonary venous isolation provided less aortic cross-clamp time and less amount of chest tube drainage with the comparable recovery and maintenance of sinus rhythm with KM. CM is a reliable and less invasive surgical option for the AF associated with mitral valve disease.

Objective: We sought to determine whether the Cox maze procedure provides additional benefit to patients with atrial fibrillation undergoing mitral valve operations., Methods: Between May 1992 and August 2000, we performed 258 Cox maze procedures with mitral valve replacement (n = 147) or mitral valve repair (n = 111). We compared the outcomes of these patients with those of 61 control patients with preoperative atrial fibrillation who underwent mitral valve replacement alone during the same interval. The three cohorts were similar in age, sex, and proportion of patients in preoperative New York Heart Association functional class 3 or 4., Results: Although 5-year survivals were similar among the groups (94% for mitral valve replacement alone, 95% for mitral valve replacement plus maze, and 97% for mitral valve repair plus maze), freedoms from atrial fibrillation at 5 years were significantly higher in the mitral valve replacement plus maze group (78%) and the mitral valve repair plus maze group (81%) than in the mitral valve replacement group (6%, P <.0001). Freedoms from stroke at 5 years were 97% for the mitral valve replacement plus maze group, 97% for the mitral valve repair plus maze group, and only 79% for mitral valve replacement group (P <.0001). Multivariable analysis with Cox hazard model revealed that the most significant risk factor for late stroke was the omission of the Cox maze procedure (P =.003)., Conclusions: The addition of the Cox maze procedure to mitral valve repair and replacement was safe and effective for selected patients. Elimination of atrial fibrillation significantly decreased the incidence of late stroke.

Background and Aims of the Study: The study aim was to elucidate the impact of the maze procedure on late outcome after valve replacement., Methods: Between 1992 and 2000, 241 patients underwent the maze procedure combined with valve replacement. Patients were allocated to three groups: aortic valve replacement (AVR/maze, n = 16); mitral valve replacement (MVR/maze, n = 148); and combined aortic and mitral valve replacement (DVR/maze, n = 77)., Results: Mean follow up was 3.9 +/- 2.3 years. Hospital mortality was 0% in the AVR/maze group, 2.0% (n = 3) in the MVR/maze group, and 3.9% (n = 3) in the DVR/maze group. Elimination of atrial fibrillation (AF) at discharge was achieved in 74.3-75.9% of cases. Freedom from recurrence of AF/atrial flutter was 71.2% in the AVR/maze group, 68.2% in the MVR/maze group, and 64.0% in the DVR/maze group at five-year follow up. By multivariate analysis, risk factors for recurrence of AF/atrial flutter included preoperative enlarged left atrial dimension >70 mm, decreased postoperative fractional shortening <30%, and absence of postoperative left atrial contraction. Freedom from stroke was 93.6% in patients who achieved regular rhythm (normal sinus rhythm or junctional rhythm), and 80.9% in those with recurrence of AF at five years after surgery (p = 0.03)., Conclusion: The combined maze procedure and valve replacement is safe and effective in selected patients. Restoration of regular rhythm significantly reduced the incidence of late stroke.

Objectives: We sought to assess the impact of diabetic retinopathy on long-term outcome among patients with diabetes and multivessel coronary artery disease (MVD) following coronary artery bypass graft surgery (CABG)., Background: For diabetics, CABG is the preferred revascularization strategy. Diabetic retinopathy is a major microvascular complication of diabetes, and its severity is directly related to total glycemic exposure., Methods: We identified 223 consecutive diabetics with MVD whose retinae were evaluated within one year prior to CABG. The most recent ophthalmologic records up until the time of CABG were used to evaluate the severity of retinopathy. The median follow-up after CABG was 11.6 years., Results: Diabetic retinopathy was a strong independent predictor of overall mortality (relative risk [RR], 4.0), and repeat revascularization (RR, 3.0). In separate analyses of diabetics with retinopathy and without retinopathy, predictors of mortality differed significantly between the two groups. Among diabetics with retinopathy, the presence of either preoperative renal (RR, 2.5) or ventricular (RR, 2.0) dysfunction had unfavorable effects on mortality, but the survival curves did not differ significantly according to the presence or absence of internal thoracic artery (ITA) grafting. In comparison, among diabetics without retinopathy, ITA grafting (RR, 0.34) had a beneficial effect on mortality, and the survival curves varied somewhat according to the presence or absence of renal or ventricular dysfunction., Conclusions: Diabetics with retinopathy had a distinct post-CABG course with a worse long-term prognosis, as compared with diabetics without retinopathy. Retina evaluation is useful for prediction of long-term prognosis and management of diabetics who need CABG.

A 17-year-old man with supravalvular aortic stenosis associated with Williams syndrome was admitted to our hospital for intensive treatment for intractable infective endocarditis. The patient had a history of percutaneous balloon valvuloplasty for aortic stenosis in 1992. He was well until late in 1999, when he had a high temperature after dental work-up. The diagnosis was infective endocarditis but antibiotic therapy was not effective. He was transferred to our clinic. Transthoracic echocardiography demonstrated bicuspid aortic valve, supraaortic stenosis, mitral valve prolapse with severe regurgitation and scattered vegetations on the anterior mitral and aortic valves. In addition, transesophageal echocardiography showed innumerable mobile vegetations located from Valsalva's sinus to the descending aorta. Aortic root and arch replacement with a homograft and mitral valve replacement with an artificial valve were successfully performed to eliminate the infective endocarditis. In the present patient, the flow jet across the supraaortic stenosis seemed to cause a predisposition to severe endocarditis.

Background and Aims of the Study: Although atrial fibrillation (AF) is often associated with severe mitral regurgitation (MR), a simultaneous maze procedure for AF associated with repair of MR remains controversial. In this study, mid-term results of combined mitral valve repair and the maze procedure were examined., Methods: Between May 1992 and April 2001, 85 patients (61 males, 24 females) underwent valve repair for MR and the maze procedure. Mean age at surgery was 61.8+/-9.1 years; mean follow up was 4.7+/-2.3 years. Valve lesions were anterior in 26 patients (31%), posterior in 31 (36%), anterior + posterior in 23 (27%), and simple dilated annulus in five (6%). Chordal replacement with expanded PTFE sutures was performed in 40 patients (47%), and leaflet resection in 41 (48%). Ring annuloplasty was also applied in 61 patients (72%). Associated procedures were tricuspid valve annuloplasty in 33 (36%), coronary artery bypass grafting in four, atrial septal defect closure in two, aortic valve repair in one, and resection of abnormal septum in the left atrium in one., Results: There was one hospital death (1%), and one late death (1%). Reopening the chest for bleeding was necessary in six cases (7%). One thromboembolic episode was detected during follow up (0.25%/patient-year). Reoperation for MR was performed in three patients (4%). Actuarial event-free survival rate was 90.0+/-6.4% at eight years. Sinus rhythm was regained in 68 patients (81%), and atrial A-wave was detected in 57 (68%) by pulsed Doppler study. Postoperative left ventricular diastolic and systolic dimensions were significantly (p = 0.001 and p = 0.017) smaller in patients who restored sinus rhythm than in those who did not (48.6+/-4.6 versus 54.6+/-4.7 mm, and 33.0+/-6.0 versus 38.1+/-6.9 mm)., Conclusion: Combined mitral valve repair for MR and the maze procedure showed satisfactory midterm results. Postoperative sinus rhythm conversion by the maze procedure may reduce left ventricular size, and the incidence of thromboembolic episodes in mitral valve repair.

Objectives: We hypothesized that the plasma atrial natriuretic peptide (ANP) level reflects atrial degenerative change and may predict the outcome of the maze procedure., Background: Although a larger preoperative left atrial dimension and longer duration of atrial fibrillation (AF) have been reported in patients with persistent AF than in those with sinus rhythm (SR), these individual factors were not enough to predict the outcome of the maze procedure., Methods: Preoperative plasma ANP levels were measured in consecutive 62 patients who underwent the Kosakai's modified maze procedure. Moreover, we performed histological and molecular biological examinations in the resected left atrial tissues., Results: The preoperative plasma ANP was lower in the AF group (n = 13) than it was in the SR group (n = 49) (p < 0.001). Multiple logistic regression analysis revealed that duration of AF and plasma ANP were independently associated with postoperative cardiac rhythm. Among 41 patients with a higher plasma ANP or shorter duration of AF than the median value, SR was restored in 95% of patients. In contrast, in 21 patients with a lower plasma ANP and a longer duration of AF than the median value, SR was restored only in 48% of patients. Histological examination revealed that the collagen volume in the left atrial tissue was higher in AF than it was in SR and inversely correlated with plasma ANP. In addition, the messenger RNA expressions of ANP, collagen type I and type III were lower in AF than they were in SR., Conclusions: These results suggest that a combination of plasma ANP and/or duration of AF may predict the success rate for the maze operation. Advanced atrial degenerative change may result in a decrease of atrial ANP secretion.

A 13-year-old boy [corrected] underwent heart transplantation for severe congestive heart failure due to dilated cardiomyopathy possibly caused by fulminant acute myocarditis. He suddenly suffered chest discomfort and loss of consciousness during running, and was referred to a hospital with cardiogenic shock. Electrocardiography showed ventricular tachycardia and echocardiography revealed severe hypokinesis in an extensive area of the left ventricular wall with markedly decreased left ventricular ejection fraction. Percutaneous cardiopulmonary support, intraaortic balloon pumping and artificial respiration were performed. He suffered from severe heart failure with septic shock and bleeding tendency. A left ventricular assist system was fitted at 73 days after onset, and he was transferred to the National Cardiovascular Center on the 119th hospital day. At 319 days after the left ventricular assist system operation, heart transplantation was performed. The etiology and treatment for severe heart failure, and several social problems which occurred during care for heart transplantation are discussed.

Background: Although off-pump coronary artery bypass grafting (OPCAB) has been widely applied in patients who are considered high risk for cardiopulmonary bypass (CPB), there is still a risk of stroke during the operation because of the ascending aortic partial clamp for proximal anastomosis. In the present study, we report the initial results of an "aorta no-touch " technique using an in-situ graft and composite and sequential grafting methods., Methods: Between March 2000 and April 2001, 120 patients underwent OPCAB with this technique. The age of patients ranged from 47 to 86 years, with a mean age of 65.7 +/- 8.7 years. On average, 3.12 +/- 0.77 grafts per patient were completed. More than 4 distal anastomoses were performed in 32 patients (27%). As in-situ grafts, 140 internal thoracic arteries (ITAs) and 9 gastroepiploic arteries were used. The radial artery (RA) was used as a Y composite graft in 91 patients, as an I composite graft in 25, and as a K composite graft in 2. Sequential bypass grafting was performed using the RA in 60 patients, the saphenous vein (SV) in 6, the ITA in 4, and the gastroepiploic artery (GEA) in 3. Arterial grafts were used in 92% (345/374) of total bypass grafts. Distal anastomosed sites were 119 left anterior descending arteries (LADs) (32%), 90 posterolateral branches (24%), 64 posterior descending arteries (17%), 49 diagonal branches (13%), 39 obtuse marginal branches (10%), and 13 right coronary arteries (3.5%)., Results: There was no operative death or stroke. Early postoperative angiography revealed 95.5% (321/336) graft patency with 100% patency (119/119) of ITA to LAD grafts. Graft patency of the ITAs and RAs (98.5% and 95.9%) were significantly better than that of the GEA (79.0%, p = 0.0064 and p = 0.030) and saphenous vein (82.3%, p = 0.011 and p = 0.048)., Conclusion: OPCAB performed with the aorta no-touch technique using an in-situ graft and composite and sequential grafting methods provides excellent early clinical results and graft patency.

A modified bicaval anastomosis technique was utilized for 4 consecutive patients undergoing heart transplantation. Instead of transecting the superior and inferior vena cavae, a strip of the posterior right atrial wall was left undivided as a bridge connecting the superior and inferior vena cavae. This minor modification perfectly prevented shrinkage and retraction of the caval tissue, thus providing easier anastomotic orientation and better estimation of the appropriate tissue length that fits well, particularly when a small donor heart was available.

Objective: We sought to investigate the durability and mechanism of the Carpentier-Edwards pericardial xenograft in the mitral position in comparison with that of the Ionescu-Shiley pericardial xenograft., Methods: A total of 284 patients who received the Ionescu-Shiley pericardial xenograft in the mitral position between 1980 and 1984 and 84 patients who received the Carpentier-Edwards pericardial xenograft in the mitral position between 1984 and 1999 were included in the study. The freedom from reoperation rates for both graft types were determined. For morphologic study, the pathologic findings of 23 valves of 123 explanted Ionescu-Shiley pericardial xenografts with structural valve deterioration, nonstructural valve deterioration, or both were determined and compared with those of 20 explanted Carpentier-Edwards pericardial xenografts with structural valve deterioration, nonstructural valve deterioration, or both. Each pathologic finding was graded and assigned a score. Both types were matched for age at reoperation (50-75 years) and duration of valve function (8-11 years)., Results: Freedom from reoperation caused by structural valve deterioration, nonstructural valve deterioration, or both was significantly better for Carpentier-Edwards pericardial xenografts than for Ionescu-Shiley pericardial xenografts at 8 years after the operation (Carpentier-Edwards pericardial xenografts: 91.3% vs Ionescu-Shiley pericardial xenografts: 71.9%, P =.0061), but it was similar for both types at 12 years (Carpentier-Edwards pericardial xenografts: 43.6% vs Ionescu-Shiley pericardial xenografts: 43.6%, P =.2865). No severe leaflet tears were seen among Carpentier-Edwards pericardial xenografts. The mean area percentage of tissue overgrowth was 15.3% in Carpentier-Edwards pericardial xenografts and 3.4% in Ionescu-Shiley pericardial xenografts (P =.0001). The mean calcification area percentage was 13.6% in Carpentier-Edwards pericardial xenografts and 31.5% in Ionescu-Shiley pericardial xenografts (P =.0001)., Conclusions: Tissue overgrowth on the atrial surface, ventricular surface, or both was the cause of structural valve deterioration, nonstructural valve deterioration, or both of Carpentier-Edwards pericardial xenografts in adults. This was different from Ionescu-Shiley pericardial xenograft failure, which resulted from severe calcification and leaflet tears. Organized thrombi on cusps, in addition to valve design, may have contributed to such tissue overgrowth on Carpentier-Edwards pericardial xenografts.

A 35-year-old man with constrictive pericarditis underwent pericardiectomy. The pericardium was dissected with a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). This new device has many advantages including no muscular stimulation, low heat, a smokeless field, and easy hemostasis. The Harmonic Scalpel is beneficial for dissection of thickened pericardium.