症例は45歳男性．後尖逸脱（P2）を伴う重症僧帽弁逆流症に対し僧帽弁形成術を施行した．胸骨正中切開直後，アナフィラキシーショックに陥り，緊急で体外循環を開始した．人工肺（A社製品）流入部の圧上昇を認めたため，即座に同社製同種の人工肺に交換した．しかし再度，圧上昇を認めたためB社製の人工肺を使用した人工心肺回路に交換した．その後は圧上昇なく体外循環を維持でき，手術を終了した．初回手術55日後に僧帽弁形成術の際のルートベント挿入部に生じた仮性瘤に対して修復術を施行することとなった．麻酔導入後，前回同様アナフィラキシーショックに陥ったが，循環維持可能であった．前回手術で流入部圧上昇を認めなかったB社の人工心肺で体外循環を開始したが，圧上昇を認めたためB社の人工肺に交換した．その後は圧上昇なく体外循環を離脱できた．人工肺流入部圧上昇の原因は不明であった．本症例は異なる2社の人工肺を用いたが，原因不明の人工肺流入部圧上昇を3度も認めた稀な症例であるため，報告する．

A 41-year-old woman presented acute cerebral infarction. Transesophageal echocardiography revealed multiple masses only on both surfaces of the aortic valve cusps. There was no primary lesion outside the heart according to various examinations. After treatment for cerebral infarction, we replaced the aortic valve instead of preservation because the intraoperative histological examination reported that malignancy was highly suspected. Contrary to the rapid frozen section diagnosis, histological and immunohistochemical examinations failed to exhibit malignancy. The tumors were composed of atypical large lymphoid cells and they were assessed to be related to T-/natural killer-cells. Furthermore, Epstein–Barr virus related markers were also positive. Her three-year postoperative course was uneventful without chemotherapy. We report an extremely rare case of Epstein–Barr virus-associated T-/natural killer-cell lymphoproliferative disease which formed multiple small tumors on both surfaces of the aortic valve.

Calcified amorphous tumor（CAT）は，1997年に初めて報告された石灰化結節を伴う非腫瘍性病変であり，透析患者や僧帽弁輪石灰化（mitral annular calcification ; MAC）に関連する症例が多いとされる．CATは全身塞栓症のリスクとされるが，CATが自己弁組織を破壊し弁膜症を来たした報告は稀である．症例は81歳女性．高血圧で近医に通院していたが，1年前より労作時の息切れを自覚するようになり，診察で心雑音を指摘され当科紹介となった．心エコー図検査で，後尖腱索断裂を伴う重症の僧帽弁閉鎖不全症を認め，また，MACと連続するように左室内へ突出する可動性の乏しい棍棒状構造物を認めた．手術適応と判断し，待機的に僧帽弁形成術を施行した．P2の弁下にMACから起始する棍棒状石灰化腫瘤を認め，また，腫瘤直上のP2腱索断裂，対側A2に弁穿孔がみられ，腫瘤により物理的に破壊された可能性が高いと考えられた．腫瘤切除，後尖P2三角切除，穿孔部閉鎖などにより僧帽弁形成可能であった．病理組織検査で，腫瘤は感染や悪性所見は認めず，CATに矛盾しない所見であった．CATは塞栓症だけでなく，自己弁組織を破壊しながら発達する場合があり，慎重な経過観察と手術時期を逸さないことが重要である．

This study was designed to establish clinical outcomes after aortic valve replacement (AVR) with On-X bileaflet mechanical heart valve.

A 63-year-old man, status post-mitral valve repair for severe mitral regurgitation secondary to ruptured chordae of the anterior leaflet, was admitted seven years after surgery because of a recent history of hematuria. A new apical pansystolic murmur was audible. Hemoglobin level was 5.7 g/dL. Results of other hematologic studies and a peripheral blood smear were indicative of mechanical hemolysis. Transesophageal echocardiography showed a high-velocity jet of mitral regurgitation that directly collided with the annuloplasty ring. At re-operation, one of the artificial neochordae to A2 and A3 segments was found to be disrupted. The mitral valve was replaced with a 33/31 mm On-X valve. Hemolytic anemia disappeared immediately after surgery. Although mitral valve repair with artificial neochodae has been shown to have long-term durability, it should be recognized that artificial neochordae may rupture a long time after mitral valve repair. Also, although hemolytic anemia is known as an early complication after mitral valve repair, it is worth knowing that hemolytic anemia may occur as a late complication after mitral valve repair. Continuous long-term monitoring of the patients after mitral valve repair is recommended. .

Background/IntroductionFast-track strategy in cardio-aortic surgery has been known to have advantages in minimizing post-operative complications, shortening hospital stay and lowering costs. Aims/ObjectivesWe reviewed our rehabilitation plan starting 2 hours after cardio-aortic operations retrospectively, in terms of feasibility and safety.

A 62-year-old female patient underwent mitral valve replacement with a 31/33-mm On-X valve for ischemic mitral valve regurgitation. Three months later, transthoracic echocardiography incidentally showed a blocked leaflet with 6 mmHg of mean pressure gradient and 2.4 cm2 of mitral valve orifice area. Transesophageal echocardiography could not detect thrombus. Electrocardiographically gated multidetector-row computed tomography (MDCT) clearly demonstrated a blocked leaflet in the close position and thrombus (2 cm in length, 0.4 cm2 in area) attached onto the atrial aspect of the leaflet. These findings observed by MDCT were confirmed at reoperation. MDCT was useful diagnostic method for visualizing prosthetic valve thrombosis.

症例は24歳女性．非定型うつ病で精神科通院中．裁縫針が胸部に刺さり抜けなくなったことを主訴に受診した．胸部X線撮影および単純CT検査で心内に金属針を認め，穿通性心損傷の診断で入院となった．気胸，心タンポナーデは認めず，循環動態も落ち着いていたため，入院翌日に左肋間小切開で異物除去術を予定していた．しかし，術前経胸壁心臓超音波検査で偶然心房中隔欠損症（ASD）を診断したため，心臓異物除去術とASD閉鎖術の同時手術の方針とした．胸骨正中切開にて心嚢に達すると，裁縫針は左前胸部から心臓に穿通する状態で確認できた．心停止後，右房を切開し，右室を三尖弁越しに確認したが，肉柱の影響もあり裁縫針は右室内腔から確認できなかった．裁縫針を抜去し，多孔性ASDは直接縫合閉鎖を行った．裁縫針の長さは35 mmであった．術後経過は良好であり，術後4日目に精神科病院へ転院となった．

This study was designed to compare the mid-term outcomes after aortic valve replacement (AVR) between 17-mm mechanical heart valves (MV) and 19-mm bioprosthetic valves (BV) in elderly patients with small aortic annuli. Between 2000 and 2011, 127 consecutive patients (mean age 79 years; 87 % female) underwent AVR for aortic valve stenosis with a small aortic annulus. 19-mm BV (n = 67) was implanted. When the 19-mm BV did not fit the annulus, 17-mm St. Jude Medical Regent prosthetic mechanical valve (n = 60) was used instead of an aortic root-enlargement procedure. The follow-up rate was 94.0 % in the BV group, and 98.5 % in the MV group. No significant differences in survival rate and valve-related complications were found between the 2 groups. In-hospital mortality rates were 1.5 % (n = 1) in the BV group and 5.0 % (n = 3) in the MV group. Late mortality rates were 3.9 % per patient-years (p-y; n = 8) in the BV group, and 6.0 % per p-y (n = 10) in the MV group. Five-year Kaplan–Meier survival rates were 62 % in the BV group, and 72 % in the MV group (log-rank P = 0.280). Freedom from major adverse valve-related stroke and cerebral bleeding events was 92.5 and 98.5 % in the BV group, and 94.7 and 100 % in the MV group. AVR using 17-mm MV in elder patients with small aortic annuli provided equivalent mid-term clinical results to that with 19-mm BV.

［目的］急性心筋梗塞（AMI）後の機械的合併症である左室自由壁破裂（LVFWR），心室中隔穿孔（VSP）に対する手術成績を検討した．［方法］2001年から2012年までに手術を実施した26例（女性14例，平均年齢74歳）を検討した．LVFWRはBlow-out型が2例，Oozing型が5例であった．搬入後4例でIABP，2例でECMOを使用した．VSPの原因は前壁梗塞が14例，下壁梗塞が5例であった．16例でIABPを使用した．手術はLVFWRにおいて縫合またはパッチ閉鎖を5例，タココンブによる止血を2例に施行した．VSPではInfarct exclusion法を17例，縫合またはパッチ閉鎖を2例に施行した．［結果］手術死亡率はLVFWR 14.3%，VSP 15.8%であった．LVFWRの死亡例は来院時心肺停止のBlow-out型症例で，低拍出量症候群を認めた．VSPの死亡例は低拍出量症候群の2例，術後8日目に心室細動で死亡した1例であった．2例のVSPにて再手術を実施した．5年生存率はLVFWR 85%，VSP 62%であった．入院後にLVFWRおよびVSPの診断が確定してからIABP始動に至るまでの時間は，使用20例中，17例の生存群にて103±45（48～120）分，3例の手術死亡群にて259±174（122～455）分で，2群間に有意差を認めた（p＝0.04）．［結論］来院後の迅速な診断，早期IABP導入，的確な手術介入などの治療戦略が，LVFWRやVSPに対して予後を改善させる可能性があると考えられた．

A 32-year-old female patient presented with shortness of breath. The patient had received aortic valve replacement with a 25-mm bioprosthetic valve at the age of 22, and had had two babies, postoperatively. Ten years later, echocardiography showed the calcifi ed bioprosthetic valve with a high peak pressure gradient (70 mmHg) and a reduced valve orifice area (0.46 cm(2)). Electrocardiographically gated multidetector row computed tomography (ECG-gated MDCT) clearly demonstrated calcifi ed bioprosthetic cusps with reduced mobility, and the valve orifi ce area was measured to be 0.64 cm(2) by direct planimetry. These fi ndings observed by ECG-gated MDCT were confi rmed at reoperation. This is the fi rst reported reoperation case of aortic structural valve deterioration clearly visualized by ECG-gated MDCT.

We evaluated the diagnostic usefulness of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve dysfunction (PVD) of an ATS valve. Twenty-four patients underwent MDCT following echocardiography and cineradiography. Echocardiography and cineradiography showed normal valve function in 17 patients and PVD in 7. PVD included aortic prosthetic valve obstruction in 4 patients, an aortic annular aneurysm with paraprosthetic regurgitation in one, and a blocked leaflet in the mitral position in 2. Among the 7 patients, 5 received reoperation after MDCT. MDCT revealed a subprosthetic mass in all 5 patients with PVD and in 4 patients with normal valve function in the aortic position. In addition to a subprosthetic mass, an annular aneurysm was found in one. Valvular masses were detected in 2 patients with mitral PVD. At reoperation, subprosthetic pannus in the aortic position was detected in 2 patients, subprosthetic pannus and annular aneurysm with paraprosthetic leaks in one, and mitral valve thrombosis in 2. These findings confirmed at reoperation matched to the findings observed on MDCT. The mean CT attenuation of the subprosthetic mass in 6 patients was 152 ± 12 HU and that of the subprosthetic pannus in 3 patients was 163 ± 17 HU. CT attenuation of the thrombus in the mitral valve in the 2 patients was 60 and 99 HU. Our study demonstrates that MDCT is a valuable and reliable diagnostic technique for PVD in an ATS valve and that MDCT may identify an abnormality causing PVD.

Postoperative bowel dysfunction is still a major unsolved problem following transperitoneal abdominal aortic surgery. We conducted this study to establish if gum chewing during the postoperative period promotes recovery of bowel function following abdominal aortic surgery.

BACKGROUND:This study was performed to evaluate the diagnostic role of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve obstruction (PVO) in the aortic position.METHODS AND RESULTS:Between 2002 and 2006, 9 patients were diagnosed with PVO of an aortic bileaflet mechanical valve based on echocardiographic and cineradiographic criteria. These 9 patients were examined using MDCT before replacement of the mechanical valve, and intraoperative findings were compared to morphologic periprosthetic abnormalities observed on MDCT. CT attenuation (Hounsfield units; HU) of the periprosthetic abnormalities was measured to investigate the underlying cause of the PVO. MDCT showed subprosthetic masses extending beyond the prosthetic ring into the orifice of the valve. At reoperation, presence of subprosthetic pannus was confirmed in all of the 9 patients, but no periprosthetic thrombus was found. The mean CT attenuation of the subprosthetic pannus was 170 HU, and it was significantly greater than that obtained from the interventricular septum (108 HU; P<0.0001).CONCLUSIONS:MDCT can be used to clearly visualize subprosthetic pannus causing PVO and the mean CT attenuation of subprosthetic pannus is significantly higher than that of the interventricular septum on MDCT.

The Carpentier-Edwards PERIMOUNT (CEP) Magna (Edwards Lifesciences, Irvine, CA, USA) is a newly developed bioprosthesis with an improved cuff design that allows its implantation into the smaller aortic annulus. We evaluated the hemodynamic performance of the CEP Magna for smaller aortic annulus cases. Patients who underwent aortic valve replacement for aortic stenosis receiving a Magna 19 mm (n = 13), were compared with a standard CEP (n = 19). In the 19-mm series, the real annular size was significantly smaller in the Magna than the standard (21.1 ± 0.8 vs. 19.8 ± 0.8 mm, p = 0.007). The Magna was significantly superior with respect to effective orifice area index (EOAI) at postoperative 3 months; however, no significant difference was seen in other factors (peak pressure gradient, left ventricular mass index, ejection fraction). At postoperative 3 months, despite the lack of statistical significance, the incidence of patient–prosthesis mismatch (PPM) was lower with the Magna. Using the same label size, the Magna can be implanted in a smaller aortic annulus with performance comparable with or better than hemodynamic performance with the standard CEP. The Magna is a useful prosthesis for the small aortic annular patient.

We herein describe a rare case of a concurrent submitral left ventricular (LV) aneurysm and an aneurysm of the sinus of Valsalva in a 65-year-old Japanese woman. The patient had a history of mitral valve replacement (MVR) for mitral regurgitation caused by a submitral LV aneurysm at the age of 58. At the time of the MVR, the orifice of the submitral LV aneurysm without thrombi was beneath the posterior leaflet, but surgical repair of the submitral LV aneurysm was not attempted. Although the patient was asymptomatic, when she underwent an echocardiogram at 65 years of age an aneurysm of the noncoronary sinus of Valsalva was detected. However, echocardiography performed before the initial operation had shown that the aneurysm of the sinus of Valsalva was coexistent with the submitral LV aneurysm. Since the submitral LV aneurysm revealed no progressive enlargement during the 7 years, patch closure of the aneurysm of the sinus of Valsalva alone was successfully performed.

BACKGROUND:Small valve size and prosthetic patient mismatch are both considered to have harmful effects on residual left ventricular hypertrophy after aortic valve replacement for aortic stenosis. In general, it is believed that the effective orifice area index of the prosthesis must not be less than 0.85 cm(2)/m(2) in order to avoid prosthetic patient mismatch. On the other hand, studies have shown that valve type and valve size had no effects on postoperative left ventricular mass (LVM). The objective of this report was to examine the relationships between patient characteristics or the prosthetic valve and postoperative LVM.METHODS:To evaluate the factors that influence postoperative LVM, we formulated the hypothesis that postoperative LVM is proportional to the sum total of pressure at the prosthetic valve orifice and inner surface area of the left ventricle in systole. We present a conceptually new index for postoperative LVM and compare the index with postoperative LVM.RESULTS:The results indicated a strong correlation between the new index and postoperative LVM six years after surgery (r(2) =0.67, p < 0.0001). As might be expected, LVM increased gradually as the value of the new index increased.CONCLUSIONS:The results of the present study indicate that postoperative left ventricular hypertrophy can be avoided by preventing postoperative hypertension in patients without left ventricular dilatation and an effective orifice area index is greater than 0.77 cm(2)/m(2).

Artificial OrgansVolume 34, Issue 12 p. 1165-1165 Reply to Letter to the Editor: Thrombolytic Treatment and Mechanical Disruption for Prosthetic Valve Thrombosis in the Right Heart Shigeaki Aoyagi MD, PhD, Shigeaki Aoyagi MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this authorShuji Fukunaga MD, PhD, Shuji Fukunaga MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this authorHideki Teshima MD, PhD, Hideki Teshima MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this author Shigeaki Aoyagi MD, PhD, Shigeaki Aoyagi MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this authorShuji Fukunaga MD, PhD, Shuji Fukunaga MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this authorHideki Teshima MD, PhD, Hideki Teshima MD, PhD Department of Surgery, Kurume University School of Medicne67 Asahi-machi, Kurume 830-0011, JapanE-mail: [email protected]Search for more papers by this author First published: 14 December 2010 https://doi.org/10.1111/j.1525-1594.2010.01162.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume34, Issue12December 2010Pages 1165-1165 RelatedInformation