Rapid-deployment aortic valve replacement after aortic root replacement: A safe alternative to redo root replacement

Reoperative aortic root replacement, following prior biologic or mechanical valved conduit aortic root prosthesis, presents a technical challenge. The rapid-deployment aortic valve prosthesis is an approved alternative to traditional bioprosthetic aortic valve replacement. We present three clinical cases in which rapid-deployment aortic valve prostheses were utilized in lieu of reoperative full aortic root replacement. All three patients recovered uneventfully. The rapid-deployment valve insertion in a prior surgical aortic root prosthesis is a safe option to avoid reoperative full aortic root replacement.     

Left coronary ostial obstruction after aortic valve replacement with a supra-annular aortic valve

We report a rare case of left coronary ostial obstruction after aortic valve replacement with a Top Hat supra-annular aortic valve, which was diagnosed with intraoperative transesophageal echocardiography and successfully treated with an unplanned coronary bypass. The patient was a 76-year-old woman (height 143 cm, weight 44 kg) with aortic stenosis and regurgitation. A 19-mm Top Hat valve was implanted in the supra-annular position because of a small aortic annulus. There was a possibility that the high profile of this prosthesis might block the left coronary ostium. There may be a problem with the use of this prosthesis in patients with small and rigid aortic roots with little compliance. Although the Top Hat valve has a great advantage for small aortic annuli, care in its use should be taken due to possible interference with the coronary ostia. (Jpn J Thorac Cardiovasc Surg 2006; 54:199-202)     

Aortic valve replacement after midline-crossed internal thoracic artery grafting

In the presence of a midline-crossed internal thoracic artery graft, a median sternotomy may jeopardize the graft and compromise hemodynamics. We report successful aortic valve replacement using a "staircase" thoracotomy and hypothermic axillary perfusion with balloon aortic occlusion in 2 men who had patent right internal thoracic artery grafts that was previously anastomosed to the left anterior descending coronary artery.     

Transcatheter aortic valve replacement in patients with anomalous left circumflex coronary artery

The anomalous left circumflex artery can be a risk for coronary stenosis or obstruction during transcatheter aortic valve replacement; however, the best procedural management has not been clarified. We describe three patients with severe aortic valve stenosis as well as anomalous left circumflex artery. In the first patient, a coronary guidewire with balloon was placed before deploying a SAPIEN 3 transcatheter heart valve, as protection from the coronary occlusion or stenosis. For the second and third patients, no coronary protection was used. All procedures were completed safely and no complications were detected at one‐year follow‐up.     

One-stage thoracic aortic aneurysm treatment and coronary artery bypass grafting

OBJECTIVE: The treatment of thoracic aortic aneurysm accompanied by ischemic heart disease presents a surgical challenge and has up to now shown a high hospital mortality rate. This report discusses the factors contributing to improved results in these cases. METHODS: We conducted a retrospective analysis of the records of 24 consecutive patients who had undergone replacement of thoracic aorta with combined coronary artery bypass grafting (CABG) between May 1991 and October 1998. Fifteen patients received total arch replacement (Arch-with-CABG Group), and the other 9 patients received the Bentall operation (Bentall-with-CABG Group). These results were compared with those patients who had undergone replacement of the thoracic aorta without CABG (Without-CABG Group). RESULTS: In the combined CABG groups, the overall operative mortality rate was 16.7%. In comparison with the Arch-without-CABG Group, there was a significantly longer cardiopulmonary bypass time and longer selective cerebral perfusion time in the Arch-with-CABG Group. However, no significant difference was observed in postoperative complications between the two groups. In addition, there was no significant difference in either actuarial survival or the cardiac-event-free rate at 5 years between the replacement of thoracic aorta with- and without-CABG Groups (83.1% vs. 90.4%, and 78.5% vs. 77.7%, respectively). No reoperation and no late death were observed during the follow-up period (mean 21.3 months). CONCLUSIONS: We concluded that replacement of the thoracic aorta combined with CABG can be carried out safely, and that revascularization for coronary artery disease is useful for preventing any occurrence of cardiac event.     

Combined mitral valve replacement and coronary artery bypass grafting through a left thoracotomy after retrosternal oesophageal reconstruction

A 74-year-old man with a history of retrosternal oesophageal reconstruction was referred for surgical treatment of mitral valve regurgitation and coronary artery disease. He underwent mitral valve replacement combined with coronary artery bypass grafting through a left thoracotomy. Combined mitral valve replacement and coronary artery bypass grafting through a left thoracotomy were feasible in this patient with a retrosternal neo-oesophageal conduit.     

Aortic valve replacement in the calcified small aortic root by hemitranslocation of the valve

An alternative technique of aortic valve replacement is described for a small aortic root with a severe large calcific degeneration of the supraaortic area at the noncoronary sinus. This technique is used when Nicks or Manouguian procedures are not applicable.     

左心室功能明显减退患者的冠状动脉旁路术

目的 探讨左心室功能明显减退患者的冠状动脉旁路移植术(CABG)的外科治疗效果。方法 回顾分析2000年12月至2002年12月对心肌梗死或长期慢性心肌缺血造成心室功能明显减退的45例冠心病患者进行CABG的相关资料。结果 42例联合应用左乳内动脉与前降支吻合。人均旁路移植3.3(1～5)支,无手术死亡。术后随访2～23个月,LVEF21.3％～65％,平均(42.7±5.9)％,与术前相比提高9％～24％(P<0.05);LVEDD55.2～64.6 mm,平均(54.7±3.8)mm。与术前相比,无明显变化(P>0.05);心绞痛完全消失39例,活动耐力增加。随访期间死亡2例。结论 左心室功能明显减退的冠心病患者,CABG手术成功率和近期效果满意,生活质量明显提高。术前合理选择病例、术中充分的再血管化和良好的围手术期处理是手术成功的关键。     

Surgically treated aortic root aneurysm following aortic valve replacement

A 65-year-old man with aortic regurgitation underwent aortic valve replacement with a St. Jude Medical prosthetic valve about 6 years ago. At that time, the aortic root was slightly dilated at about 40 mm in diameter and the ascending aorta was within the normal range. This year, the man was diagnosed with an aortic root aneurysm in regular follow-up echocardiography. Chest-enhanced computed tomography and chest aortography at our hospital demonstrated a pear-like aortic root aneurysm about 60 mm in diameter. Elective operation for the aortic root aneurysm was conducted September 29, 1999, based on the Bentall procedure. Composite graft replacement with coronary reconstruction was conducted using a 28-mm Hemashield prosthetic graft and a 23-mm St. Jude Medical prosthetic valve under cardiopulmonary bypass. An 8-mm Hemashield graft was interposed on the left main coronary artery and the right coronary artery was directly anastomosed using a Carrel patch method. The postoperative course was uneventful and post-operative examination demonstrated good surgical results. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. Surgical cases of aortic root aneurysm after aortic valve replacement are rare, but serious complications with the possibility of rupture or dissection warrant surgical intervention.     

Coronary artery bypass grafting to a calcified right coronary artery

A severely calcified coronary artery demands a special technique in coronary artery bypass surgery. We have successfully developed a "punch-out" technique for a calcified right coronary artery in a dialysis patient. After an incision into the target coronary artery, the calcified arterial wall was resected using a punch to make an oval hole for anastomosis. Limited endarterectomy, which consisted of dissection and removal of the calcified endothelium and media around this hole, preserving the adventitia, enabled the anastomosis. This technique can be used for a severely calcified coronary artery that is unamendable to conventional coronary artery bypass grafting.     

Severely calcified bicuspid aortic valve stenosis after valve-sparing root replacement: A word of caution

A 58-year-old man was admitted for reoperation for severe aortic stenosis in a previously preserved bicuspid aortic valve (BAV). He had undergone valve-sparing root replacement (VSSR) for dilated aortic root 6 years ago. Transesophageal echocardiography following VSSR showed good valve function with no aortic incompetence. However, the BAV became stenotic causing shortness of breath. At reoperation, the preserved BAV was noted to be fibrotic and calcified and had a fixed rigid small orifice. It was replaced with a biological valve plus root enlargement. Macroscopic finding showed thickening of the cusps and nodular calcification. Microscopic examination revealed severe nodular calcification.     

Intraoperative right coronary artery obstruction due to aortic root prosthesis mismatch after aortic valve replacement—A case report

Iatrogenic intraoperative coronary artery ostial occlusion is quite rare and a dangerous complication of aortic valve replacement. Intraoperative vigilance and prompt intervention are required to manage this fatal complication. A case report of a 48‐year‐old female with normal coronaries who underwent aortic valve replacement and had right ventricle distension is described here. It seemed that the cause which led to right coronary ostial obstruction was due to prosthesis aortic root mismatch and it required bypass with a vein graft. Computed tomographic angiography of aortic root showed abutting of right coronary ostium by the aortic valve prosthesis     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting

The Usefulness of Brachial Artery Cannulation, Perfused Ventricular Fibrillation with Moderate Hypothermia, and Minimal Dissection Techniques It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76-year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient’s postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.     

Anaesthesia for off-pump coronary artery bypass grafting

Achieving surgical revascularization of the heart, while avoiding the insult of cardiopulmonary bypass, is particularly desirable in specific high-risk patient groups. The relatively recent advances in surgical technique allowing high-quality grafting without mechanical arrest have led to an increase in popularity of off-pump coronary artery bypass surgery. Nonetheless, operating on the beating heart, manipulating it and purposely inducing ischaemia, invariably has significant haemodynamic consequences which must be carefully yet aggressively managed. To compound the situation, the intraoperative monitoring typically employed to evaluate cardiac function, such as electrocardiography and echocardiography, are of limited efficacy at crucial moments in the procedure. It is therefore essential that the anaesthetist is able to assimilate information from a multitude of sources in order to safely navigate the patient through a period of continually changing cardiovascular stress.     

Anaesthesia for off-pump coronary artery bypass grafting

Achieving surgical revascularization of the heart, while avoiding the insult of cardiopulmonary bypass, is particularly desirable in specific high-risk patient groups. The relatively recent advances in surgical technique allowing high-quality grafting without mechanical arrest have led to an increase in popularity of off-pump coronary artery bypass surgery. Nonetheless, operating on the beating heart, manipulating it and purposely inducing ischaemia, invariably has significant haemodynamic consequences which must be carefully yet aggressively managed. To compound the situation, the intraoperative monitoring typically employed to evaluate cardiac function, such as electrocardiography and echocardiography, are of limited efficacy at crucial moments in the procedure. It is therefore essential that the anaesthetist is able to assimilate information from a multitude of sources in order to safely navigate the patient through a period of continually changing cardiovascular stress.