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.

Refractory Perioperative Hypotension in Off-Pump Coronary Artery Bypass Grafting in a Patient with Schizophrenia / 日本心臓血管外科学会雑誌

A 57 year-old man with angina pectoris was transferred to our hospital for coronary artery bypass grafting. His past history was schizophrenia and paroxysmal atrial fibrillation. He had been taking major tranquilizers for 20 years. Off-pump coronary artery bypass grafting (RITA-LAD, LITA-OM-D2, Ao-SVG-#4PD-#14PL) and bilateral pulmonary vein isolation was performed. During the distal anastomosis, systolic blood pressure was decreased and bolus infusion of norepinephrine and phenylephrine were not effective. Vasopressin was injected (1U/shot), and stabilized his hemodynamic status without any mechanical support. After the operation, vasopressin was continued to postoperative day (POD) 4. There was no side effect related to vasopressin. He was discharged from the hospital on POD 12. When major tranquilizers are taken for a long time patients can be resistant, or overreact to catecholamine. Vasopressin can be a valid option as a vasopressor for such catecholamine refractory hypotension.

Autotransplantation and Concomitant Pneunectomy for an Intracardiac Metastatic Lesion and Primary Pulmonary Blastoma of the Left Lung / 日本心臓血管外科学会雑誌

Pulmonary blastoma is rare and its prognosis very poor. A 6-year-old boy was referred to our hospital with chest pain. Computed tomography demonstrated that the left pleural cavity was filled with a tumor. Cardiac echocardiography demonstrated that the tumor had invaded through the pulmonary vein into the left atrium and that the tumor extended into the left ventricle. Part of the tumor was adhered to the anterior leaflet of the mitral valve. To increase operative radicality, an autotransplantation technique was performed concomitantly with resection of the original lesion. Through a median sternotomy, a moderate hypothermic cardiopulmonary bypass was established to obtain cardiac arrest. First, longitudinal incision of right-sided of the left atrium was made. The tumor invaded into the left atrium through the left superior pulmonary orifice. The ascending aorta, the main pulmonary artery, and both caval veins were transected. The left atrium was incised along the pulmonary venous orifices. The heart was completely removed from the mediastinum and transferred to another table. Resection of the intracardiac metastatic lesion and mitral valve replacement was accomplished. During this time, thoracic surgeons performed a left pneunectomy. The left atrial wall around the left pulmonary venous orifices was resected in combination with the left lung. After the deficit of the left atrial wall was repaired with a Gore-Tex patch, the heart was replaced and we reconstructed the great arteries and caval veins. The autotransplantation technique is a useful procedure for combined lesions of the heart and lung.