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Ann Thorac Surg 2002;74:236-237
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kushiro Hospital, Kushiro, Japan
b Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication October 25, 2001.
* Address reprint requests to Dr Harada, Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kushiro Hospital, 1-4-26 Sakuragaoka, Kushiro-shi, Hokkaido 085-0805, Japan
e-mail: hideyuki.harada{at}pref.hokkaido.jp
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Abstract |
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Introduction |
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A 14-year-old boy sustained chest trauma with dislocation of the left sternoclavicular joint during a motorcycle accident. On admission to the hospital, he complained of anterior chest pain and became dyspneic. Chest roentgenograms revealed hemothorax and an enlarged heart. Electrocardiography suggested broad anterior myocardial infarction, and chest computed tomography showed contusion of the left lung, bilateral posterior intrapulmonary hemorrhage, and bleeding in the mediastinum. Because of these findings, immediate coronary arteriography was not performed. The patient required respiratory ventilation for 5 days, after which he recovered gradually. Echocardiography demonstrated dyskinesis of the anterior left ventricular wall, grade 3 mitral regurgitation, and grade 2 tricuspid regurgitation.
Three weeks after the accident, the patient underwent coronary arteriography, which showed discrete proximal dissection of the left main coronary artery (Fig 1). The rest of the artery was normal, as was the right coronary artery. Left ventriculography showed a left ventricular aneurysm, a left ventricular ejection fraction of 0.25, and grade 3 mitral regurgitation (Fig 2). Despite treatment with vasodilators and diuretics, the patient continued to experience shortness of breath on slight exertion, and therefore he was referred for surgical intervention.
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After angioplasty of the left main coronary artery was completed, the left ventricular aneurysm was incised. A broad area of the endocardium and part of the papillary muscle were necrotic, and these were partially excised. The aneurysm wall was resected, and ventriculorrhaphy was performed. The mitral valve annulus was markedly dilated. The middle portion of the anterior mitral leaflet and the lateral portion of the posterior mitral leaflet were prolapsed. The prolapsed area of the anterior leaflet was corrected by chordal shortening, and a quadrangular posterior leaflet resection was followed by 28-mm ring annuloplasty to reduce the tension on the annulus. The annulus of the tricuspid valve was also dilated, and a De Vega annuloplasty was performed [3]. Cardiopulmonary bypass was discontinued smoothly during intraaortic balloon pumping. The total cardiopulmonary bypass time was 267 minutes, and the aortic cross-clamp time was 231 minutes.
The patient was weaned from the intraaortic balloon pump on the first postoperative day, and thereafter the course was uncomplicated. Echocardiography demonstrated modest improvement in ventricular wall motion (EF, 0.40), although grade 2 mitral regurgitation remained after the operation. Postoperative coronary arteriography revealed smooth blood flow in the left main coronary artery (Fig 3). The patient was discharged and continues to do well 4 years postoperatively.
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Comment |
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Because no ideal prosthetic valve is available, operations in young patients with cardiac valve disease should be designed to conserve the native valve whenever possible. However, preservation of the valve cannot always be accomplished, and in such patients, a prosthesis must be placed. Use of anticoagulants in young patients with mechanical prostheses poses special dangers because these patients are active and thus have a higher likelihood of trauma [6]. Furthermore, prosthetic valve size mismatch can develop as the patient grows. Anticoagulation is not required in young patients with a bioprosthesis, but reoperation is very likely, as the prosthesis will degenerate over time.
Therefore, bearing in mind the future active school life of the patient, we carried out valvuloplasty with ring annuloplasty for mitral regurgitation and partial papillary muscle necrosis. Although mild mitral regurgitation remains, our patient has done well in the 4 years since operation. We will continue to observe him closely in the future.
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