A Case of Antiphospholipid Syndrome Underwent Cardiac Surgery Performed Using Coagulation Management by Measuring Heparin Concentration during Extracorporeal Circulation / 日本心臓血管外科学会雑誌

A 72-year-old female was diagnosed with systemic lupus erythematosus and antiphospholipid syndrome (APS) in 2014 and was followed up. Severe mitral regurgitation coexisted with APS, but the case was nonsymptomatic, and surgery involved high risk. Therefore, the physicians continued their observation. In 2020, the patient experienced rheumatic severe mitral stenosis and shortness of breath on exertion. Paroxysmal atrial fibrillation and coronary stenosis were also detected. Therefore, we planned mitral valve replacement, tricuspid annuloplasty, coronary artery bypass, pulmonary vein isolation and left atrial appendage closure. During extracorporeal circulation (ECC), we performed coagulation management based on blood heparin concentration using HMS PLUS. Because the APS patient showed prolonged activated clotting time (ACT), and coagulation therapy based on ACT is unreliable. She was discharged from our hospital on postoperative day 23. No complications, including bleeding and thrombosis, were observed 2 years after the operation. We experienced a case of APS who underwent cardiac surgery and performed coagulation management by measuring heparin concentration during ECC. We targeted a 3.5 U/ml heparin concentration, and her clinical course was uneventful.

Surgical Tumor Resection and Reconstruction of the Inferior vena cava under Cardiopulmonary Bypass for Right Renal Cell Carcinoma Extending into the Right Ventricle / 日本心臓血管外科学会雑誌

In cases of renal cell carcinoma causing embolism in the inferior vena cava, aggressive surgical resection is recommended and expected to improve the prognosis. The patient was a 52-year-old man who had been on hemodialysis since the age of 45 due to diabetic nephropathy. A CT scan for anemia revealed a tumor in the right kidney, and the patient was referred to the urologist at our hospital. A thorough examination revealed a diagnosis of primary right renal carcinoma with tumor embolization in the inferior vena cava (IVC) that extended to the right ventricle. During surgical resection of the tumor, a midline abdominal incision was made. The liver was detached and exposed to the IVC by the gastroenterological surgeon, followed by dissection of the right kidney for removal by the urologist. The wound was then extended to the anterior chest, and a mid-thoracic incision was made. The SVC was snared, and a right atrial incision revealed a tumor. We resected the tumor at the level of the diaphragm while blocking the IVC, and sutured the right atrium. The IVC was then incised centrally from the confluence of the right renal veins to identify the renal tumor that was resected from the lumen along with the venous wall. The missing IVC wall was reconstructed with an expanded polytetrafluoroethylene (ePTFE) patch. In this case, the patient received complete resection of a right renal cell carcinoma, with inferior vena cava embolism and tumor extending into the right ventricle, using extracorporeal circulation. He was discharged on the 29th day after surgery without any major postoperative complications. The use of cardiopulmonary bypass is considered to be an effective means of ensuring surgical safety in cases of complete resection of malignant tumors that have spread from the IVC to the heart.

Surgical Explantation of Difficult Removal PICC Involving Intravascular Compound in a Child Case / 日本心臓血管外科学会雑誌

The peripherally inserted central catheter (PICC) is widely used as a central venous catheter for both pediatric and adult patients. Fewer procedure-related complications have been reported than for conventional methods using the internal jugular, femoral, or subclavian veins for access. On the other hand, thrombosis and phlebitis are more common than in conventional methods, and sometimes the catheter cannot be removed by manual traction. In this study, a 13-year-old girl had received long-term sedation from a PICC due to neurodegenerative disease. The patient was referred to our department because of difficulty in manual drawing for removal of the PICC. A CT scan showed that the PICC was bent at the right axillary vein and there was a high-density area around it. Surgical treatment was chosen after a joint conference between the department of pediatrics and us to discuss the reliability and invasiveness of the several treatments. Under general anesthesia, an incision was made under the right subclavian bone, and her axillary vein was exposed. The lumen of the vein was filled with a white plaster-like compound, and the catheter itself was buried inside it. The compound was removed, and the bent PICC was straightened and removed from the puncture site. There is no other case for difficult removal of PICC in this form without calcification. We believe that surgical removal was effective in this case because of her vascular structure.