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1/113. String-plucking as a mechanism of chordal rupture during balloon mitral valvuloplasty using inoue balloon catheter.

    Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in a 59-year-old female with mitral stenosis and a severely calcified mitral leaflets. Although not entrapped in the subvalvular apparatus, the balloon catheter was deviated away from the mitral orifice-apex axis of the left ventricle during the inflation of the proximal balloon, which plucked and severed the chordae tendineae of the posterior mitral leaflet and resulted in severe mitral regurgitation.
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2/113. Transcatheter closure of a patent foramen ovale following mitral valve replacement.

    We report the successful closure of a postoperative patent foramen ovale in a patient who underwent coronary artery bypass grafting and mitral valve replacement for severe mitral insufficiency. The postoperative course was complicated by severe hypoxemia due to a large patent foramen ovale. The patient underwent transcatheter closure with the Das Angel Wings transcatheter occluder (Microvena Corporation, White Bear Lake, MN) with immediate improvement.
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keywords = foramen
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3/113. Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle.

    A 61-year-old man was admitted with acute posterior myocardial infarction and, on physical examination, was shown to have a mitral regurgitation (MR) murmur. Transthoracic echocardiography (TTE) showed severe hypokinesis of the posterior wall and severe MR by color flow. Right heart catheterization with a balloon-tipped catheter revealed a pulmonary artery wedge pressure of 30 mmHg. No 'step-up' was seen in blood samples from the right atrium and right ventricle. On angiography, a subtotal occlusion of the mid circumflex artery was found which was angioplastied and stented. As the patient's clinical condition did not improve, he underwent transesophageal echocardiography (TEE) for further evaluation. This showed complete rupture of the posteromedial papillary muscle. The patient underwent urgent surgery with successful mitral valve replacement. The postoperative course was uncomplicated, and clinical improvement seen. This case report underscores the value of TEE in accurate preoperative diagnosis of papillary muscle rupture by providing preoperative anatomic details of the mitral valve apparatus and surrounding structures.
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4/113. Systolic anterior movement of mitral valve during acute apical myocardial infarction: An unusual mechanism of acute mitral regurgitation.

    We describe a singular case of a 75-year-old woman affected by an anterior acute myocardial infarction in the subset of a very recent orthopaedic surgery. She had had severe mitral regurgitation on coronary angiography. A thorough cardiac echocardiographic examination revealed the particular mechanism of mitral incompetence, consisting of a dynamic anterior mitral leaflet displacement caused by a sustained compensatory left ventricle hypercontractility and favored by postsurgical moderate anemia and mild hypertensive hypertrophy. The use of beta-blockers and the avoidance of pure vasodilators permitted complete reversal of such mechanisms during the clinical course.
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5/113. Pathological and neuropathological findings in two males with fragile-X syndrome.

    The present paper addresses post mortem pathological and neuropathological findings in two males with fragile-X syndrome, aged 67 and 87 years. Both subjects died from sudden, unexpected cardiovascular causes, and both showed abnormalities of the mitral valve, ventricular hypertrophy and cardiomegaly. Both cases demonstrated macrocephaly characteristic of the classical Martin-Bell phenotype in FRAXA. There was increased brain weight in both cases: macroscopically, both cerebral and cerebellar hemispheres appeared normal, but dilated lateral ventricles were seen; and microscopic examination of the brain in case 2 showed normal hexalaminar architecture and no gross neuronal dropout. The hippocampus showed mild CA4 pyramidal cell loss and associated gliosis. The cerebellum showed focal Purkinje cell loss and corresponding Bergmann gliosis. Whilst there is a need to delineate the microscopic features of fragile-X syndrome from those of the ageing process, there is an urgent need for more systematic neuropathological studies of fragile-X syndrome; the increased brain weight and Purkinje cell loss in autism and fragile-X syndrome reopens the debate on these two conditions. The case for further research into the cardiac anomalies in fragile-X syndrome is also strengthened by the findings. Finally, the present report confirms the role of interstitial cell hyperplasia as the major cause of megalo-testes in this condition.
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keywords = ventricle, cerebral
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6/113. A case of constrictive pericarditis with local thickening of the pericardium without manifest ventricular interdependence.

    This is the first case report of postsurgical constrictive pericarditis confined to the left ventricle in which the majority of diagnosis tests were not indicative of the disease. A 50-year-old woman with a past history of mitral valve replacement was admitted for right heart failure. cardiac catheterization showed impaired diastolic filling but lacked the characteristic ventricular interdependence recently reported to be specific for the disease, without manifest radiological appearance of pericardial thickening. However, a new technique using magnetic resonance tagging cine revealed pericardial adhesion, limited to the left ventricle, which was confirmed during pericardiectomy. After the surgery, right heart failure and diastolic filling abnormality disappeared with restoration of normal heart pressures.
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7/113. endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child.

    Varicella is generally a benign, self-limited childhood illness; however, severe, life-threatening complications do occur. A live, attenuated vaccine exists to prevent this illness, but controversy remains concerning the need to vaccinate children for what is generally a benign, self-limited disease, although more states are currently recommending this vaccine. We report a previously healthy 3-year-old who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed group A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocarditis of a normal heart valve. We are unaware of previous reports of endocarditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, aortic valve endocarditis was diagnosed. A 6-week course of intravenous penicillin g was administered. Two weeks after the initiation of therapy, the diastolic murmur was harsher, and echocardiography revealed a large vegetation on the posterior leaflet of the aortic valve, with severe aortic insufficiency and a dilated left ventricle. The patient subsequently developed congestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worsening aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by aortic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GABHS after varicella, illustrates the need for the health care practitioner to consider both common and life-threatening complications in patients with varicella. While cellulitis, encephalitis, and septic arthritis may be readily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superinfection should also be entertained. The case we report is unique in that the patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally normal heart with a previously unreported pathogen. Although a child may have been vaccinated against varicella, the chance of contracting the virus still exists and parents should be informed of this risk. group A beta-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella.
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8/113. Batista's operation with coronary artery bypass grafting and mitral valve plasty for ischemic dilated cardiomyopathy.

    A 52-year-old male was admitted for angina pectoris and congestive heart failure classified as new york Heart association class III. coronary angiography showed 95% stenosis in the left anterior descending artery, 99% stenosis in the first diagonal branch, total occlusion in the left circumflex artery, and a hypoplastic right coronary artery. Left ventriculography showed a severely dilated left ventricle (ejection fraction 20%) and mild mitral regurgitation. In the myocardial scintigram using 99m-tetrofosmin, there was no viability in the posterolateral wall although the other wall was viable. Partial left ventriculectomy, which is called Batista's operation, coronary artery bypass grafting and Alfieri's mitral valve plasty were performed concomitantly. Postoperatively, the ejection fraction was improved to 39%, and all grafts were patent. The patient was discharged in new york Heart association class I. We concluded that to succeed in partial left ventriculectomy for ischemic dilated cardiomyopathy, not only should there be no viability in the posterolateral wall to be resected for volume reduction, but the coronary artery which perfuses the residual myocardium with viability should be graftable.
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9/113. Hypertrophic obstructive cardiomyopathy associated with mitral regurgitation due to infective endocarditis.

    A 25-year-old woman treated for hypertrophic obstructive cardiomyopathy and suffering from mitral regurgitation due to infective endocarditis was referred to our department for surgery. Preoperative examinations revealed asymmetric septal hypertrophy, a large left ventricular outflow gradient (100 mmHg), and perforation of the anterior mitral leaflet resulting in severe mitral regurgitation. The entire mitral complex was resected and septal myectomy conducted to dilate the left ventricle. A bioprosthetic valve was then implanted. Although postoperative heart failure was severe, cardiac function has gradually recovered. The left ventricular outflow gradient has decreased to 8 mmHg, the diastolic left ventricular diameter has increased from 26 to 30 mm, and her new york Heart association classification has improved from IV to I.
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10/113. Atrial blood cyst in an adult with regurgitation of mitral and tricuspid valves.

    blood cysts of the heart are extremely rare in adults and usually involve valves or the left ventricle. Although two cases of blood cysts in the right atrium in adults have been reported, a cyst combined with a disorder of the valves has never been reported. We report a 52-year-old woman with a blood cyst that generated from the right atrial septum. Furthermore, the patient had regurgitation of both the mitral and tricuspid valves and then underwent surgical excision of the blood cyst, mitral valve plasty and tricuspid valve annuloplasty. We believe that it is possible to diagnose blood cysts with echocardiography, CT and magnetic resonance imaging. echocardiography showed the cyst as a circle without a complete inner free-echo. CT and magnetic resonance imaging showed a mass with a non-enhanced inner structure. Furthermore, the latter showed a cyst that was enhanced by T1- but not T2-weighted images, indicating that the content of the cyst was a persistent substance such as blood. Concerning the generation of blood cysts, we hypothesize that heteroplastic growth arising from primitive pericardial mesothelium causes disorders of valves and blood cysts.
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