ABSTRACT
<i>Aspergillus </i>infective endocarditis (ASIE) is a very rare disease that carries an extremely poor prognosis. We report a case of ASIE successfully treated by a tricuspid valve replacement and administration of an antifungal drugs. The patient was a 69-year-old man who was taking steroids for an autoimmune disease and was admitted to our hospital because of a persistent fever of 39°C. As chest CT showed infiltrative shadows in both lung fields and the <i>aspergillus </i>antigen was detected in the blood, we diagnosed invasive pulmonary aspergillosis (IPA), and initiated administration of micafungin sodium (MCFG). Later, the patient's heart failure worsened, and echocardiography revealed vegetation measuring 8 mm in diameter in the anterior cusp of the tricuspid valve. As this indicated a definitive diagnosis of ASIE, administration of voriconazole (VRCZ) was initiated. However, the vegetation grew into a movable wart measuring 20 mm in diameter within a week, based on which a diagnosis of drug-resistant ASIE was made, and surgery was considered indicated. Very large vegetations were found in the anterior cusp of the tricuspid valve, anterior papillary muscle, the tendinous chord of the medial papillary muscle and the trabeculae carneae of the right ventricle. Based on the findings, it was judged that tricuspid annuloplasty was impossible and tricuspid valve replacement was performed using a biological valve. As to the antifungal medication, long-term administration of VRCZ and MCFG was continued. The patient followed a favorable course and was discharged from the hospital on the 220th day. The patient aking lifelong VRCZ and has shown no evidence of recurrence of the ASIE. To improve the prognosis of ASIE, rapid and radical surgical resection of the vegetations and appropriate administration of antifungal drugs are important.
ABSTRACT
A 47-year-old man suffered an idiopathic esophageal rupture and an emergency operation was performed. Postoperative CT revealed an aortic dissection at the level of the infra-renal aorta and the right common iliac artery. The maximum diameter of the aorta was 3.0cm, and that of the right common iliac artery was 2.5cm with a patent false lumen. The operation was done using the right extra-peritoneal approach. When the infra-renal aorta was clamped and opened, the false lumen was located on the right anterior wall of the aorta. There were 3 communicating holes presumably being the points of entry or re-entry. A bifurcation Dacron graft was put into the aorta and the bilateral iliac artery. His postoperative course was good and he was discharged on the 15th day after surgery. In this case, since the patient had no history of severe pain except for the time of esophageal rupture, the localized abdominal aortic dissection was suspected to have simultaneously occurred with the idiopathic esophageal rupture.
ABSTRACT
A 63-year-old man was admitted due to acute congestive heart failure. Transesophageal echocardiography demonstrated quadricuspid aortic valve malformation with concomitant severe aortic regurgitation. The valve was replaced by a 21mm Edward-MIRA and the postoperative course was uneventful. Although quadricuspid aortic valve is a rare anomaly, its potential for severe valve failure in adulthood should not be neglected.
ABSTRACT
We reviewed the clinical course of 127 patients who underwent treatment for atherosclerotic disease between June 1993 and January 2001. There were 108 men and 19 women. The ages ranged from 49 to 88 years with a median age of 71.2 at the time of the first operation. Major risk factors included ischemic heart disease (21%) and diabetes mellitus (20%). Ninety-five percent of the patients were followed successfully and the follow-up period ranged from 0 to 90 months with a mean of 33 months. Two patients died perioperatively due to myocardial infarction. There were 29 late deaths. The overall actuarial survival rate was 69.7% at 5 years. The 5-year actuarial survival rate and the mean survival time for men and women were 71.6%, 66.1 months and 62.3%, 58.9 months. The 5-year late survival rate and the mean survival time for patients with and without ischemic heart disease were 57.0%, 57.4 months and 74.2%, 68.5 months. The differences were not statistically significant. The 5-year late survival rate and the mean survival time for patients with and without diabetes mellitus were 65.5%, 59.1 months and 70.9%, 67.4 months. The differences were not statistically significant. Amputation was performed in 7 patients, the actuarial survival rate at 1 year and the mean survival time were 42.9%, 7.1 months for patients with amputation, and 93.0%, 69.5 months without amputation (<i>p</i><0.01).
ABSTRACT
A 68-year-old man with a right common iliac artery aneurysm perforating the inferior vena cava showed cardiomegaly and pulmonary congestion with left leg edema and dyspnea on exertion. The patient demonstrated a hyperdynamic circulation characterized by increased filling pressure, low systemic resistance, and high cardiac output (9.81<i>l</i>/min/m<sup>2</sup>) before surgery with a pulmonary-to-systemic blood flow ratio of 1.36. At operation, the right iliac artery to the inferior vena cava fistula, 5×10mm across, was closed along with resection and replacement of the aneurysm with a woven dacron graft of 10mm in diameter. The procedure caused acute and dramatic changes both in pre- and after-loads associated with aortic clamping as well as with elimination of A-V shunt through the fistula. Diligent attention was required both by surgeons and anesthesiologists to cope with these rather dramatic hemodynamic shifts during and after surgery. The patient did well and was discharged with normal hemodynamic parameters.