Acute Stanford Type A Aortic Dissociation with Simultaneous Cerebral Hemorrhage : a Rare Case / 日本心臓血管外科学会雑誌

The case concerns a seventy-one-year old male patient on maintenance dialysis. He experienced chest discomfort and called for emergency conveyance. He was diagnosed with acute Stanford type A aortic dissection with open false lumen and expanded hematoma around the aorta using computed tomography (CT). The patient was referred to our hospital for emergent surgical intervention. At the time of admission to our hospital, cerebral hemorrhage in the left thalamus and right head of caudate nucleus was revealed on a CT head scan. On neurologic examination, a slight drop in exercise ability was demonstrated in the right arm. We shared the images offline with a neurosurgeon in a neighboring hospital. After the consultation, surgery for the acute aortic dissociation was canceled due to concerns about cerebral hemorrhage aggravation with the use of an intraoperative anticoagulant. Although there was no indication for surgical intervention for the cerebral hemorrhage at that point, he was placed under careful observation. Hemodialysis using nafamostat mesilate was restarted ; fortunately, there was no exacerbation in the cerebral hemorrhage. However, a CT scan revealed expansion of the false cavity of the ascending aorta on the fifth day post-diagnosis. After confirming no exacerbation of cerebral hemorrhage on CT on the fifth, sixth, and seventh days, graft replacement of the ascending aorta and concomitant aortic valve replacement for aortic valve stenosis were performed on the eighth day. He was extubated on the first postoperative day. He left the ICU on the sixth postoperative day. Neither increase of hematoma on the postoperative CT, nor any exacerbation of the neurologic symptoms was observed. On the forty-seventh postoperative day, he was shifted back to the referring hospital for rehabilitation.Acute aortic dissection with simultaneous onset of cerebral hemorrhage is very rare. Though both conditions are critical, there are no guidelines for treatment, and decisions on the treatment strategy are unclear. In this case of acute Stanford type A aortic dissection, there was a concern about the exacerbation of cerebral hemorrhage with the use of an intraoperative anticoagulant. We report the successful surgical repair of acute aortic dissection one week after onset as a viable therapeutic option in cases where emergency intervention is not possible due to associated complications.

Postoperative Acute Kidney Injury and Efficacy of Continuous Hemodiafiltration after Cardio-Thoracic Surgery / 日本心臓血管外科学会雑誌

Background and Purpose : Patients who undergo cardiac and thoracic vascular surgery are known to have a high risk of developing acute kidney injury (AKI). The incidence of post-operative acute renal failure and the utility of continuous hemodiafiltration (CHDF) for acute renal failure following cardiovascular surgery was determined. Subjects and Methods : Of the 321 subjects who underwent cardiac and thoracic vascular surgery accompanied by an open thoracotomy from January 2014 to August 2017, 303 patients were included in this study after excluding those who received maintenance dialysis and those treated with PCPS. Patients were grouped based on the GFR classification of CKD severity (preoperative eGFR values : G1 : ≥90, G2 : <90, G3a : <60, G3b : <45, G4 : <30, G5 : <15) and patient records were retrospectively examined. Results : The total incidence of AKI was 30.7%. In comparison with G1 and G2, the AKI incidence rate was significantly higher (p<0.01) in G3a, G3b, G4, and G5 patients who displayed preoperative renal dysfunction. Upon multivariate analysis, preoperative eGFR values were shown to be a predictor of post-operative AKI avoidance with a cutoff value of 56 ml/min/1.73 m2 (odds ratio = 4.104, AUC = 0.6954). The post-operative CHDF introduction rate was 3.6%. After introduction of CHDF, patient urine volume and body blood pressure significantly increased (p < 0.01). In 2 cases, a rapid increase of urine volume (2.5 ml/kg/h, 1.8 ml/kg/h) was observed within 1 h after the induction of CHDF. Conclusions : A high rate of post-operative AKI onset occurs in cardiac and thoracic surgery cases. Upon early introduction of post-operative CHDF, prompt recovery of renal function and stabilization of circulatory dynamics can be expected.

Susceptibility of Aedes flavopictus miyarai and Aedes galloisi mosquito species in Japan to dengue type 2 virus

Objective: To evaluate the potential of local mosquitoes to act as vectors for dengue transmission in Japan. Methods: Serotype 2 ThNH28/93 was used to test the dengue susceptibility profiles of Aedes flavopictus miyarai (Ae. f. miyarai), Aedes galloisi (Ae. galloisi) and Aedes albopictus (Ae. albopictus), which were collected in Japan. We used Aedes aegypti from Thailand as a positive control. The mosquitoes were infected with the virus intrathoracically or orally. At 10 or 14 days post infection, the mosquitoes were dissected and total RNA was extracted from their abdomens, thoraxes, heads and legs. Mosquito susceptibility to dengue virus was evaluated using RT-PCR with dengue virus-specific primers. Differences in the infection and mortality rates of the different mosquito species were tested using Fisher's exact probability test. Results: The infection rates for dengue virus administered intrathoracically to Ae. f. miyarai, Ae. galloisi and Aedes aegypti mosquitoes were identical by RT-PCR on Day 10 post infection. All of the body parts we tested were RT-PCR-positive for dengue virus. For the orally administered virus, the infection rates in the different body parts of the Ae. f. miyarai mosquitoes were slightly higher than those of Ae. albopictus mosquitoes, but were similar to the control mosquitoes (P > 0.05). The mortality rates for Ae. f. miyarai and Ae. albopictus mosquitoes were similar (P = 0.19). Our data indicated that dengue virus was able to replicate and disseminate to secondary infection sites in all of the four mosquito species (Japanese and Thai). Conclusions: Ae. albopictus is a well-known candidate for dengue transmission in Japan. However, our data suggest that Ae. f. miyarai from Ishigaki Island (near Okinawa Island) and Ae. galloisi from Hokkaido (Northern Japan) should also be regarded as potential vectors for dengue transmission in these regions. Further studies on these mosquitoes should be conducted.

Hemodiafiltration during Off-Pump Coronary Artery Bypass Grafting for a Chronic Dialysis Patient / 日本心臓血管外科学会雑誌

Patients on chronic hemodialysis, undergoing coronary artery bypass grafting (CABG) have high perioperative mortality and morbidity. In order to reduce the perioperative risks, we performed intraoperative hemodiafiltration (HDF) during off-pump CABG (OPCAB). A 62 year-old-man, who had been on dialysis for 2 years, was admitted with a sensation of chest compression. A coronary angiography revealed 75% stenosis with severe calcification in the left anterior descending artery and 90% stenosis in the second diagonal branch. During the operation, veno-venous HDF was started, using a double lumen catheter that was introduced into the femoral vein at the same time that a skin incision was made. During the exposure of the diagonal branch by rotating the heart, the blood flow of HDF was decreased and dehydration was halted to avoid hemodynamic deterioration. The patient was extubated 1.5h after the operation and did not require continuous hemodiafiltration (CHDF) in the intensive care unit (ICU). Routine hemodialysis was restarted on the 3rd postoperative day. The postoperative course was uneventful, and the patient was discharged to home on the 11th postoperative day. HDF during OPCAB for this chronic dialysis patient was observed to be effective and yielded an excellent postoperative recovery without CHDF in the ICU.