RPO should be recognized as one of the most serious complications after MICS with right mini-thoracotomy. More accurate risk factors of prolonged lung malperfusion and steroid use on RPO after MICS should be investigated.

Regional cerebral oximetry using near-infrared spectroscopy device, an INVOS 5100 C (Medtronic, Minneapolis, MN, USA), during cardiac surgery aims to avoid perioperative neurological impairment, especially during cardiopulmonary bypass. However, it is not uncommon to encounter critically low initial cerebral regional oxygen saturation or a low value unresponsive to intervention. Therefore, it is important to identify factors associated with low saturation value other than true cerebral hypoxia. We investigated the relationship between preoperative regional cerebral oxygen saturation and clinical variables during cardiac surgery. From January 2013 to May 2016, 462 patients underwent elective cardiac surgery. Patient's ≤12 years of age, with acute cerebral infarction, with previous intracranial hemorrhage or neurosurgery, with concomitant aortic surgery, and having off-pump coronary artery bypass surgery were excluded. The remaining 223 patients were monitored by intraoperative regional cerebral oximetry. Univariate analysis found that scalp-cortex distance, cerebrospinal fluid thickness, left ventricular ejection fraction, hemoglobin concentration, estimated glomerular filtration rate, and hemodialysis were significantly correlated with the initial regional oxygen saturation value. Multiple regression analysis revealed that scalp-cortex distance, left ventricular ejection fraction, hemoglobin, and hemodialysis remained as significant variables. A receiver operating characteristic analysis found that for a low initial regional oxygen saturation value of 40%, the thresholds of scalp-cortex distance, left ventricular ejection fraction, and hemoglobin concentration were 17.6 mm, 45.2%, and 7.5 g/dl, respectively. In conclusion, brain atrophy, poor left ventricular function, anemia, and hemodialysis were associated with low initial cerebral regional oxygen saturation values in adult cardiac surgery patients.

SummaryFenestration-related massive aortic regurgitation is rare. The underlying mechanism is reported to be rupture of the fenestrated fibrous strand, and most ruptured cords have been reported in the bicuspid valve or in the right coronary cusp of the tricuspid aortic valve. We encountered a rare case of acute aortic regurgitation due to fibrous strand rupture in the fenestrated left coronary cusp. Preoperative echocardiography detected left coronary cusp prolapse, and operative findings revealed rupture of a fibrous strand in the left coronary cusp. For cases such as this, preoperative echocardiography would be useful for appropriate diagnosis. (Int Heart J 2014; 55: 550-551) Key words: Aortic valve regurgitation F enestration in the aortic valve is not uncommon and is often observed in normal subjects. In this type of aortic valve, the fibrous strand, which is said to be an embryonic remnant during semilunar cusp formation, is a supportive tissue that maintains aortic valve coaptation. Fibrous strand rupture causes acute aortic regurgitation (AR) and has been reported to occur in the congenital bicuspid valve or in the right coronary cusp of the tricuspid valves.1) Here we report the case of a patient with a fenestrated tricuspid aortic valve with a fibrous strand. The patient had a history of hypertension and suffered from acute AR due to fibrous strand rupture in the left coronary cusp. Case ReportA 76-year-old man underwent aortic valve replacement with a bioprosthetic valve (23 mm) for acute AR. He had a history of hypertension, and his blood pressure was poorly controlled despite medication. Chest X-rays revealed gradual worsening of cardiomegaly since the initiation of medication therapy at 66 years of age. He had no history of rheumatic heart valve disease.At the age of 75 years, moderate AR was identified with echocardiography. However, he did not have any definite symptoms at that time, and medication therapy was continued instead of surgical treatment. Dyspnea on exertion became gradually more severe, and he was transferred to our hospital due to acute heart failure. His blood pressure was 220/96 mmHg and the control of blood pressure was very poor. His body temperature was 36.7°C, and no inflammatory response was observed. Auscultation revealed a diastolic murmur (Levine III/VI) at the right second intercostal sternal border. Chest X-rays revealed cardiomegaly (cardiothoracic ratio = 65%) and pulmonary edema. His electrocardiogram showed a strain T pattern (concentric hypertrophy) in V5 and V6. Serum brain natriuretic peptide (BNP) was extremely high at 426 pg/mL. Echocardiography showed a dilated left ventricular chamber (left ventricular diastolic dimension: 57 mm) with fair contraction (ejection fraction = 50%). The aortic valve was tricuspid; however, fenestrated cusps with fibrous strands were detected in the right coronary cusp and noncoronary cusp. The left coronary cusp was prolapsed and had dropped into the left ventricular chamber. A ruptured fibrous strand was attached to the left co...

SummaryTogether with aging of the Japanese population, aortic valve replacement (AVR) for aortic stenosis (AS) is now becoming more and more common in the elderly. When the aortic annulus is too small to allow an adequate sized prosthetic valve, aortic root enlargement is required to avoid prosthesis-patient mismatch (PPM). However, age-related comorbidities including aortic root calcifi cation bring signifi cant risk in performing aortic root enlargement. In the present study, 40 patients aged 75 years or more who underwent AVR for AS were reviewed to determine whether moderate PPM has a negative impact on the long-term results. Operative mortality occurred in 2 patients (5%) and moderate PPM occurred in 8 patients. There was no signifi cant difference in survival between cases with and without PPM (P = 0.87). Both aortic pressure gradient (PG) and left ventricular mass index (LVMI) measured by echocardiography were significantly decreased in patients with and without PPM. Reduction of PG was signifi cantly greater in patients with PPM than without PPM (P = 0.02). Reduction of LVMI was not different between the groups (P = 0.58). Moderate PPM did not negatively infl uence survival or reduction of PG or LVMI in patients aged 75 years or older who underwent AVR for AS. (Int Heart J 2013; 54: 11-14)

In this study of patients with acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta, the mortality of those who declined initial aortic surgery was 62% at 30 days and 67% at 90 days, respectively, and a smaller aortic diameter was significantly associated with better survival.