Temporary axillo-femoral bypass for abdominal aortic aneurysm repair in high risk patients.

Abdominal aortic aneurysm (AAA) is sometimes associated with coronary artery and valvular disease. We report the successful treatment of a 76-year-old woman diagnosed with an infrarenal AAA, associated with severe mitral regurgitation and double-vessel coronary artery disease. First, AAA repair, using temporary axillo-femoral bypasses on both sides was done. Second, after 77 days, we simultaneously undertook coronary artery bypass grafting (CABG) and mitral valve repair. This staged operation achieved an excellent result. This rarely used abdominal aortic surgical procedure contributed to minimizing variations in afterload, an important consideration in high risk cardiac patients.     

Oblique aortic valve replacement and coronary artery bypass grafting for severely calcified narrow aortic root with unstable angina

We report an 84-year-old woman diagnosed with aortic stenosis and regurgitation with a severely calcified narrow aortic root and left main coronary artery trunk stenosis with triple-vessel coronary artery disease. Emergency aortic valve replacement and triple coronary artery bypass grafting were successful. The aortic annulus was small and heavily calcified, and the ascending aorta, the sinus of valsalva and the anterior leaflet of the mitral valve were severely calcified. A St. Jude Medical valve 19A (St. Jude Medical Inc., St. Paul, MN) was inserted obliquely along the noncoronary sinus. This technique is a useful alternative in cases where the patient's life is at risk in situations involving severe extensive calcification of a narrow aortic root.     

A reoperation of adult-Type Bland-White-Garland syndrome

We present a 25-year-old female patient with Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) who underwent mitral valve replacement (MVR) and coronary artery bypass grafting. She had previously undergone MVR and had been treated by the Takeuchi procedure for mitral valve regurgitation and a coronary artery anomaly, respectively, at 17 years of age. She was hospitalized with shortness of breath within 7 years of surgical intervention. Swan-Ganz catheterization revealed mild pulmonary hypertension and elevated mean pulmonary wedge pressure. Echocardiography revealed marked severe calcification of the bio valve and moderate mitral valve regurgitation. Coronary angiography revealed retrograde collateral blood flow from the right coronary artery to the left coronary artery, but intrapulmonary tunnel was not visualized by pulmonary arteriography. We performed MVR with a mechanical valve and coronary artery bypass grafting between the left internal thoracic artery and the left anterior descending artery. The postoperative course was unremarkable, and no complaints were reported during follow-up at the outpatient clinic.     

Successful combined operation for Takayasu's arteritis.

We report a case of Takayasu's arteritis complicated with aortic regurgitation and severe stenosis of the left coronary ostium and the innominate artery. Simultaneous surgical treatment of aortic valve replacement, coronary ostium endarterectomy, and aortosubclavian artery bypass using saphenous vein were performed. We discuss the choice of simultaneous operation and the option of surgical treatment for coronary ostium lesion due to Takayasu's arteritis.     

An approach to mitral valve surgery by a T-shaped mini-sternotomy with functioning bilateral internal thoracic artery grafts

We herein report successful surgical treatment of mitral valve regurgitation in a 49-year-old man. He was admitted to our hospital due to acute aggravation of dyspnea on effort. He had a surgical history of coronary artery bypass grafting with bilateral internal thoracic artery grafts. A transthoracic echocardiogram showed severely decreased cardiac function and severe mitral regurgitation due to anterolateral mitral valve leaflet prolapse. Computed tomography showed the right internal thoracic artery running over the front of the aorta to the left circumflex artery. To avoid injury to the functioning grafts during median sternotomy, we chose to perform an inferior T-shaped mini-sternotomy. The surgical field was sufficient to perform mitral valve replacement with a mechanical prosthetic valve under fibrillatory arrest. The grafts were neither dissected nor clamped, and access to the aorta and mitral valve was excellent.     

Aneurysm of the left sinus of Valsalva causing aortic, mitral regurgitation and myocardial ischemia.

An aneurysm of the left sinus of Valsalva producing aortic and mitral regurgitation with myocardial ischemia was treated successfully by reconstructing the left coronary sinus while preserving the aortic cusp combined with coronary artery bypass grafting. Aortic and mitral regurgitation occurred due to distortion of the left aortic cusp by a huge aneurysm that also compressed and obstructed the main trunk of the left coronary artery. The postoperative course was uneventful and follow-up showed aortic and mitral regurgitation to be absent and the coronary graft to be patent. Aortic valve-sparing surgery thus proved to be an appropriate procedure for this case.     

Simultaneous repair of stenosis in coronary and vertebral arteries and aortic regurgitation secondary to Takayasu's aortitis

We report a case of severe stenosis in the ostium of both the coronary artery and the proximal left vertebral artery and severe aortic regurgitation secondary to Takayasu's aortitis. A 47-year-old woman underwent simultaneous repair consisting of aortic valve replacement, triple coronary artery bypass grafting, and aorto-left vertebral artery bypass. Saphenous vein grafts to 3 coronary arteries and the left vertebral artery were proximally anastomosed on a bovine pericardial patch in the ascending aorta. Since the patient had severe preoperative ischemic symptoms from vertebral-basilar insufficiency, we clamped the vertebral artery during reconstruction under deep hypothermic circulation. The postoperative course was uncomplicated. Simultaneous repair of such multiple lesions requires meticulous planning of surgical procedures and circulatory assist systems.     

Beating heart surgery for ischemic mitral regurgitation: report of a case

A 51-year-old man was admitted to our hospital because of dyspnea. Coronary angiography revealed triple vessel disease and echocardiography demonstrated severe mitral regurgitation with poor left ventricular function. Under a diagnosis of ischemic mitral regurgitation, on-pump beating mitral annuloplasty and coronary artery bypass grafting using the normothermic retrograde continuous coronary sinus perfusion of oxygenated blood was performed in order to prevent reperfusion injury. The patient was easily weaned from cardiopulmonary bypass and his postoperative course was uneventful. Because of the advantages of this procedure (e.g., no reperfusion injury, testing of the mitral valve repair is done in real physiologic conditions with beating tonus), on-pump beating heart surgery seems a good surgical option for ischemic mitral regurgitation with poor left ventricular function.     

Simultaneous repair of stenosis in coronary and vertebral arteries and aortic regurgitation secondary to Takayasu''s aortitis

We report a case of severe stenosis in the ostium of both the coronary artery and the proximal left vertebral artery and severe aortic regurgitation secondary to Takayasu's aortitis. A 47-year-old woman underwent simultaneous repair consisting of aortic valve replacement, triple coronary artery bypass grafting, and aorto-left vertebral artery bypass. Saphenous vein grafts to 3 coronary arteries and the left vertebral artery were proximally anastomosed on a bovine pericardial patch in the ascending aorta. Since the patient had severe preoperative ischemic symptoms from vertebral-basilar insufficiency, we clamped the vertebral artery during reconstruction under deep hypothermic circulation. The postoperative course was uncomplicated. Simultaneous repair of such multiple lesions requires meticulous planning of surgical procedures and circulatory assist systems.     

Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone

We have favored treatment of moderate mitral regurgitation and coronary disease with coronary bypass alone because of the high operative mortality of combined mitral valve replacement and coronary bypass. Between 1977 and 1983, coronary bypass alone was performed on 58 patients (mean age 63 +/- 8 years). Preoperatively, 90% had Canadian Cardiovascular Society class III or IV angina, and 10% had class III or IV congestive heart failure. In 72% mitral regurgitation had been caused by coronary disease. Hospital mortality was 3.4% (2/58). At follow-up (100% complete, mean 4.3 years) 66% of survivors were functional classes I and II (compared with 7% preoperatively, p less than 0.0001). Of those patients who worked preoperatively, 84% returned to work. There were no reoperations. The 5-year survival was 77%. In the same period combined mitral valve replacement and coronary bypass was required in 20 unmatched patients with moderate mitral regurgitation and coronary disease. Indications for valve replacement included congestive heart failure (10 cases), high left atrial pressure (three cases), and mitral stenosis (four cases). In these patients with more advanced symptoms the hospital mortality was 25%, and the 5-year survival was 31%. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone achieved excellent hospital survival and long-term functional stability without a subsequent valve operation.     

Surgical results for mitral regurgitation from coronary artery disease

Results of coronary artery bypass grafting with and without mitral valve replacement were analyzed retrospectively in 101 patients with preoperative ischemic mitral regurgitation to determine the effects of severity and surgical treatment of mitral regurgitation on survival. Between 1980 and 1984, a total of 1,475 patients (mean age 59, 77% male) underwent coronary bypass. These patients were divided into three groups: (1) patients without ischemic mitral regurgitation who underwent isolated coronary bypass (1,374; 93%), (2) patients with ischemic mitral regurgitation who underwent isolated coronary bypass without valve replacement (85; 6%), and (3) patients with ischemic mitral regurgitation who underwent combined mitral valve replacement and coronary bypass (16; 1%). Preoperatively, patients with ischemic mitral regurgitation compared to those without regurgitation were significantly older (+6 years, p less than 0.001), had more severe coronary artery disease (p less than 0.001), a higher incidence of congestive heart failure (24% versus 5%, p less than 0.001) and recent myocardial infarction (16% versus 8%, p less than 0.01), and a lower mean ejection fraction (45% versus 61%, p less than 0.001). Operative mortality was significantly increased in patients with ischemic mitral regurgitation who underwent coronary bypass alone (p less than 0.01) and in those who underwent coronary bypass and mitral valve replacement (p less than 0.01)--11% and 19%, respectively--than in the coronary bypass patients without ischemic mitral regurgitation (3.7%). The severity of mitral regurgitation (0 to 4+) proved to be the most significant predictor of operative mortality. The actuarial survival rate at 5 years for the coronary bypass patients without ischemic mitral regurgitation was 85% compared to 91% (p less than 0.05) for the coronary bypass patients without ischemic mitral regurgitation. These results indicate that patients with ischemic mitral regurgitation have a higher prevalence of cardiac risk factors and are at an increased risk of operative mortality. Although the severity of the ischemic mitral regurgitation was strongly predictive of early survival, it proved to have an unexpectedly modest effect on long-term survival after surgical treatment.     

Combined operation for left atrial myxoma, mitral regurgitation, coronary artery stenosis and abdominal aortic aneurysm

A 68-year-old male patient with a left atrial myxoma, mitral regurgitation, ischemic heart disease and abdominal aortic aneurysm underwent resection of the myxoma, mitral valve replacement, 4 coronary artery bypass grafting and replacement of the aneurysm simultaneously. The aneurysm was replaced under partial cardiopulmonary bypass. Combined cardiac and abdominal aortic operation is useful in selected patients who require IABP support postoperatively or whose cardiac function is poor.     

Aortocoronary bypass for coronary ostial stenosis following aortic valve replacement: a report of successfully treated case

A 62-year-old man underwent aortic valve replacement with a Medtronic-Hall valve (21 mm) for aortic stenosis and regurgitation with normal coronary arteries. An intermittent selective coronary perfusion with metal tip cannula was employed for both the coronary arteries. Postoperative course was uneventful. However, he began to complain of chest pain six months later. Cardiac catheterization and coronary arteriography revealed a normally functioning valve with 75% stenosis at the main trunk of the left coronary artery. Coronary bypass grafting using a saphenous vein was successfully performed to the left anterior descending coronary artery and the circumflex of the coronary artery. Whenever this fatal complication of the coronary ostial stenosis is recognized, earlier coronary revascularization should be recommended to save the severely ill patient.     

Aortic and mitral valve replacement for calcified valvular annulus in a dialysis patient; report of a case

A 77-year-old man on hemodialysis was admitted to our hospital due to heart failure. Echocardiography showed aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitaion, and tricuspid valve regurgitation. Catheter examination revealed severe calcification at aortic valve and mitral valve including their annulus. At the operation, the calcifications of the aortic and mitral valvular annulus was removed using a cavitron ultrasonic surgical aspirator (CUSA). Reconstructions of the defect of the posterior part of the mitral annulus and of the aortic annulus at the site of the left coronary cusp were achieved by patch technique using autologous pericardium. Aortic and mitral valve replacement and tricuspid valve annuloplasty were performed. The postoperative course was uneventful. Operative technique to remove calcification from valvular annulus using CUSA and reconstruct of the defect of the annulus with autologous pericardium is a very useful technique to prevent left ventricular rupture, perivalvular leakage and any other complications.     

Clinical outcomes of surgery of mitral valve regurgitation and coronary artery bypass grafting

The impact of etiology of associated mitral valve regurgitation and a valve procedure on operative and long-term outcomes after coronary bypass grafting surgery is yet to be clearly defined. Results of combined coronary artery bypass grafting and valve procedures for mitral valve regurgitation were retrospectively analyzed in 468 patients. The regurgitation was of ischemic in 45%, degenerative in 55% and 78% valve repairs, 22% valve replacements were performed. Severe coronary artery disease, acute myocardial infarction, low ejection fraction, ischemic mitral regurgitation, advanced heart failure symptoms, failure to use internal mammary artery, valve replacement surgery, and emergency operations are predictors of operative mortality. The 5-year survivals for propensity-matched patients of ischemic and degenerative disease were similar (66%), but 67% vs. 83%, respectively, for unmatched patients. Low ejection fraction (<35%), advanced age (>67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term survival. Left ventricular remodeling processes, optimal valve procedure without residual mitral regurgitation and left ventricular function are important determinants of long-term outcome than the etiology of valve regurgitation.     

A case of aortitis syndrome with left coronary ostial stenosis and aortic regurgitation treated by transaortic coronary endarterectomy and aortic valve replacement

A case, 23-year-old female of aortitis syndrome with left coronary ostial stenosis and aortic regurgitation was reported. The coronary angiography showed critical stenosis of the left coronary ostium with intact main stem and its branches. The aortogram revealed aortic regurgitation of grade III, and multiple obstructive or stenotic lesions on the left common carotid artery, the origin of the left renal artery, the inferior mesenteric artery and the abdominal aorta. After improvement of inflammatory findings by steroid therapy during 2 months, transaortic coronary endarterectomy and aortic valve replacement with 21 mm Bj?rk-Shiley valve were performed successfully. Postoperative course was uneventful. Coronary angiography performed at the 57th day after the operation showed complete removal of the left coronary ostial stenosis, and aortography showed no evidence of perivalvular leakage of the aortic valve prosthesis. The indication of transaortic coronary endarterectomy and the technique used to avoid aortic valve detachment which may be caused by recurrence of aortitis were discussed in this paper.     

Iatrogenic left main and proximal right coronary artery stenoses after aortic valve replacement.

Iatrogenic left main coronary artery stenosis after aortic valve replacement is an infrequent but potentially life-threatening complication. A 44-year-old woman who had normal coronary arteries documented by preoperative coronary angiogram, and who developed severe stenosis of the left main coronary artery and subtotal occlusion of the proximal right coronary artery after aortic and mitral valve replacements is presented. Coronary lesions were clinically manifested 4 months after the first operation. Accurate diagnosis was confirmed by repeat coronary angiography. She underwent successful coronary artery bypass grafting.     

Transaortic delivery of the transmitral lesion in a complete maze procedure

A 68-year-old hypertensive diabetic woman with chronic atrial fibrillation presented with progressive congestive symptomatology. She was diagnosed with severe aortic stenosis, moderate mitral regurgitation, and critical right coronary artery stenosis. In addition to coronary revascularization and bioprosthetic aortic valve replacement, she underwent a mitral valve repair and a complete cryoMaze procedure through a transaortic approach. This technique obviates a separate left atriotomy for the mitral repair and Maze procedure. It affords excellent exposure, while reducing cross clamp and cardiopulmonary bypass time as well as avoiding the potential sequelae of bleeding and traction injuries resulting from a left atriotomy.     

Two cases of off-pump coronary artery bypass grafting combined with abdominal aortic aneurysm repair.

Two cases of coronary artery disease coexisting with abdominal aortic aneurysm were treated with off-pump coronary artery bypass grafting combined with repair of the aneurysm. The first patient was a 67-year-old man exhibiting a large pulsating abdominal mass. Abdominal computed tomography demonstrated a 9-cm aneurysm and coronary angiogram revealed a 90% stenosis of the obtuse marginal branch for which percutaneous transluminal angioplasty could not be performed. He underwent simultaneous single coronary artery bypass grafting without cardiopulmonary bypass, and bifurcated graft replacement. The second patient was a 71-year-old man who had acute myocardial infarction, and one month later underwent coronary angiogram which revealed three vessel disease in the coronary artery. Computed tomography revealed a 4-cm aneurysm, and angiography showed a 90% stenosis of the left renal artery. He underwent a single stage operation that involved three coronary artery bypass grafting without cardiopulmonary bypass, straight graft replacement, and reconstruction of the left renal artery using the saphenous vein graft. The postoperative course was uneventful in both cases. We currently recommend a single stage operation involving off-pump coronary artery bypass grafting.     

Posterior ventricular aneurysm, severe mitral regurgitation, and rupture of the left ventricle after acute myocardial infarction: six-year survival after surgical correction.

Posterior ventricular aneurysm and severe mitral regurgitation due to acute myocardial infarction are rarely recognized during life. This report describes the successful surgical treatment of a patient with this combination of lesions who at operation was found to have rupture of the left ventricle as well. Aneurysmectomy, mitral valve replacement, and coronary artery bypass were performed with a gratifying late result. Aggressive investigation of patients with hemodynamic deterioration after posterior myocardial infarction may identify surgically correctable mechanical complications.