A Sandwich Technique Employing Right Ventricular Incision to Repair Posterior Ventricular Septal Rupture with Right Ventricular Wall Dissection: A Case Report

Background: Ventricular septal rupture (VSR) leading to right ventricular (RV) wall dissection is an extremely rare and life-threatening complication of inferior myocardial infarction (MI) with posterior VSR. Its rare incidence and complex pathology make it difficult to select the appropriate surgical procedures to prevent fatalities. Case Presentation: A 68-year-old woman was transferred to our hospital because of a post-infarction VSR 12 days after symptom onset. Short-axis image obtained using transthoracic echocardiography demonstrated a large posterior VSR. Moreover, the VSR was continuous, with a large echo-free space in the posterior wall of the right ventricle. Color echocardiography showed blood flowing into the echo-free space through the septal defect and blood flowing out into the RV lumen. Coronary angiography revealed complete occlusion of the second segment of the right coronary artery. Thus, dissection of the posterior wall of the right ventricle that continued into the RV lumen was considered to have been caused by the posterior VSR caused by an inferior MI. The patient underwent urgent surgery to repair the VSR using the sandwich double-patch technique by making a posterior RV incision that was repaired using a third patch. No additional procedure was required to block the flow from the cavity of the RV wall dissection into the RV lumen. Postoperative echocardiography and contrast-enhanced computed tomography demonstrated that the VSR was closed securely and the RV wall dissection was almost completely thrombosed. Conclusion: In this case, a patient with a posterior VSR and RV wall dissection was successfully treated using the sandwich double-patch technique with a posterior RV incision. No additional procedure may be needed for RV wall dissection when a secure VSR repair is complete;however, close follow-up is essential to improve the long-term prognosis.

Supraceliac Aortic Clamping for Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Short Aortic Neck Length

Objective: Prompt bleeding control with proximal aortic clamping and subsequent aortic repair are very important for ruptured abdominal aortic aneurysm. However, unsuitable anatomy, such as short aortic neck length, not only disturbs the means to an expeditious repair, but may also increase morbidity and mortality. In the present study, we aimed to evaluate the efficacy of supraceliac aortic clamping for improving surgical outcomes for patients with ruptured abdominal aortic aneurysm, who have a short aortic neck length. Method: Between April 2010 and September 2015, eighteen patients underwent emergent open surgical repair of ruptured abdominal aortic aneurysm. Eight patients with a short aortic neck length underwent supraceliac aortic clamping, and 10 underwent infrarenal aortic clamping. Results: The mean supraceliac aortic clamping time was 30 ± 7 minutes. There was 1 operative death in the infrarenal aortic clamping group due to respiratory failure, and the overall operative mortality was 6%. There were no significant differences between the 2 groups with respect to postoperative complication rates or mortality. Furthermore, there were no significant differences in variables of renal function between the 2 groups, through-out the study period. Conclusion: Supraceliac aortic clamping was associated with minimal mortality and morbidity, but not with harmful effects on postoperative renal function. Thus, supraceliac aortic clamping can be safely applied for ruptured abdominal aortic aneurysm with short aortic neck length.

Right Atrial Blood Cyst Incidentally Detected by Computed Tomography for Metastatic Breast Cancer in an Adult Female Patient: A Case Report

Cardiac blood cysts are benign congenital cardiovascular tumors that are rare in adults. A 70-year-old woman who underwent left mastectomy for left breast cancer 9 years ago was referred to our institution for a right atrial mass that measured 35 × 30 mm and was detected incidentally by computed tomography for metastatic breast cancer and transthoracic echocardiography. The mass was attached to the interatrial septum by a stalk. Although it was asymptomatic, surgical resection was performed because of the risk of pulmonary embolism. The mass contained blood, and histopathological findings were suggestive of a blood cyst. We described a rare case of a right atrial blood cyst incidentally found during evaluation for metastatic breast cancer in a woman.

Significance of Cold Renal Perfusion on Renal Function and Clinical Outcomes When Renal Ischemia Time Exceeded 30 Min during Pararenal and Juxtarenal Abdominal Aortic Aneurysm Surgery

Objectives: To investigate the influence of cold renal perfusion on renal function and clinical outcomes in cases where the renal ischemia time exceeded 30 min during pararenal and juxtarenal abdominal aortic aneurysm (P/JAAA) surgery. Methods and Results: Fifty-four patients who underwent open repair for P/JAAAs were retrospectively analyzed. Thirty-nine patients received renal perfusion with cold Ringer’s solution (perfusion group) and 15 patients did not receive renal perfusion (non-perfusion group). There were no significant differences in preoperative serum creatinine level (Cr) (1.08 ± 0.42 vs. 1.35 ± 0.71 mg/dL, p = 0.09), percentage of patients with Cr > 2 mg/dL [2/38 (5%) vs. 2/15 (13%), p = 0.8], and renal ischemia time during proximal aortic clamping (49 ± 21 vs. 47 ± 11 min;p = 0.8) between the groups. Postoperative Cr was significantly lower in the perfusion group than in the non-perfusion group (1.48 ± 0.76 vs. 2.23 ± 1.21 mg/dL, p < 0.01). The percentage of patients with postoperative Cr > 2 mg/dL was also significantly lower in the perfusion group than in the non-perfusion group [5 (13%) vs. 7 (47%), p < 0.01)]. At discharge, Cr returned to preoperative levels in both groups. All patients were discharged from the hospital without incidents. Conclusion: Renal artery perfusion with cold Ringer’s solution clearly reduced the deterioration of postoperative renal function compared to non-renal perfusion.

Left Ventricular Reconstruction and Mitral Valve Annuloplasty Combined with Papillary Muscle Relocation for Severe Ischemic Mitral Regurgitation

A 46-year-old man was referred to our hospital due to severe ischemic mitral regurgitation with severe bileaflet tethering and a dilated left ventricle. We performed left ventricular reconstruction and mitral valve annuloplasty combined with papillary muscle relocation. Although left ventricular continued remodeling occurred during follow-up, left ventricular reconstruction and mitral valve annuloplasty combined with papillary muscle relocation provided durable mitral repair, and his functional status was good. Thus, this combined surgical treatment may reduce mitral regurgitation recurrence after mitral valve annuloplasty.

Maintenance of High Blood Pressure and Early Establishment of Pulsatile Blood Flow to the Spinal Cord during Thoracoabdominal Aortic Repair

Objectives: Despite continuous advancements in the surgical treatments for thoracoabdominal aortic aneurysms (TAAA), paraplegia remains a devastating treatment-related complication. We aimed to summarize our experience with a novel surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile blood flow to the spinal cord. Materials and Methods: Between August 2011 and October 2017, 29 patients (age, 67 ± 12 years) underwent open surgery for TAAA. According to the Crawford classification, two aneurysms were type I, eight were type II, 12 were type III, and seven were type IV. We used partial cardiopulmonary bypass under mild hypothermia in all patients except one. By maintaining distal aortic perfusion pressure at 60 - 80 mmHg and creating the distal aortic anastomosis before visceral branch reconstruction, we established early perfusion of the hypogastric arteries with native pulsatile flow. Intraoperative spinal monitoring and cerebrospinal fluid drainage were performed in 26 (90%) and 23 (79%) patients, respectively. Nineteen patients (66%) underwent reconstruction of the intercostal arteries. During perioperative management, the mean arterial pressure was kept >80 mmHg. Results: No in-hospital deaths or acute neurological complications occurred. One patient (3.4%) experienced delayed temporal paraplegia. During follow-up, aorta-related death occurred in only one patient, who developed prosthetic vascular graft infection but did not undergo repeat graft replacement. The 3-year freedom from aortic-related death was 95%. Conclusion: Our surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile flow to the spinal cord was effective in preventing spinal cord injury following open surgery for TAAA.