ABSTRACT
The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : <i>n</i>=73) and group B (the early rehabilitation group : <i>n</i>=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (<i>p</i><0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (<i>p</i><0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (<i>p</i><0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (<i>p</i><0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (<i>p</i><0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (<i>p</i><0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (<i>p</i>=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.
ABSTRACT
With the progressive aging of the Japanese population, cardiac surgeons are increasingly faced with elderly patients. We have studied 29 consecutive patients, 80 years of age or older, who underwent aortic valve replacement at our institution between January 2000 and December 2003. Mortality, morbidity and late follow-up results were compared to those in 36 patients aged from 64 to 75 years old undergoing the same procedure over the same time period. The older patient group had a significantly higher incidence of calcified aortic stenosis and emergency operations and a higher score of NYHA functional class. Hospital mortality was 2 of 29 (6.9%) in the older patient group and 2 of 36 (5.6%) in the control group (ns). Postoperative renal failure and respiratory failure which needed prolonged ventilator support occured significantly more often in the older patient group. However, there was no significant difference between the 2 groups in terms of hospital stay. Almost all octogenarians showed improved NYHA functional class to class I or II after the operations. The actuarial survival rate was 89% in the older patient group and 78% in the control group at 3 years. The late survival rate and cardiac event-free rate were not significantly different between these 2 groups. Following aortic valve replacement, octogenarians, despite more compromised pre-operative status had good relief of symptoms, a favorable quality of life and a similar late survival to the younger patient groups. These findings support the recommendation that valve replacement should be performed in octogenarians with symptomatic aortic valvular disease.
ABSTRACT
A 62-year-old man, who had been given a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital for an operation for abdominal aortic aneurysm (AAA). Preoperative coronary angiography revealed severe triple vessel disease, and we chose to treat this first. The platelet count on his first admission was 2.1×10<sup>4</sup>/μl and preoperative immunoglobulin infusion was introduced for 5 days. Off-pump coronary artery bypass grafting (OPCAB) was performed safely with platelet transfusion, and he was discharged on the 14th postoperative day. Thirty-eight days later, graft replacement of AAA was performed with preoperative immunoglobulin infusion and no platelet transfusion, and he was discharged at the 11th postoperative day. Preoperative immunoglobulin infusion therapy and selection of OPCAB were useful to prevent perioperative bleeding complications. This is the first report of staged cardiac and aortic surgery in a patient with ITP.
ABSTRACT
A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.
ABSTRACT
A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO<sub>2</sub>, low level of PaO<sub>2</sub> and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/<i>l</i> and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.
ABSTRACT
A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.
ABSTRACT
An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.
ABSTRACT
A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. <i>Klebsiella pneumoniae</i> was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.
ABSTRACT
A successfully treated case of a 73-year-old man with mycotic aneurysm of the iliac artery combined with psoas abscess was reported. The operation consisted of débridement of the infected arterial wall with arterial reconstruction using autologous reversed superficial femoral vein and wrapping the graft and filling the defects with omentum. <i>Streptococcus pneumoniae</i> was grown from the psoas abscess culture. He had peritonitis by gangrenous cholecystitis postoperatively and underwent reexploration for correction of the peritonitis. After his second operation, the postoperative course was uneventful. He is doing well 18 months postoperatively. Venous morbidity after superficial femoral vein harvest is minimal. <i>In situ</i> reconstruction with autogenous deep leg veins is a successful option in patients with mycotic aneurysms.
ABSTRACT
From 1995 till 1998, 21 cases of Stanford type A dissecting aortic aneurysm with a closed false lumen of the ascending aorta were treated in our institute. The patients were medically treated if the diameter of their ascending aorta stayed less than 50mm without recurrent dissection. Patients were categorized into three groups: Groups I, II and IIIR (retrograde dissection), according to the location of the entry analyzed by means of CT, angiography and operative findings. Seven cases of intramural hematoma (IMH) were included in this study. One case in Group II died of rupture and one case in Group IIIR died of multiple embolism caused by atrial fibrillation in the acute phase. One case in Group II died of stroke and one case in Group I died after surgery in the chronic phase. Four cases in Group I and II underwent surgery in the acute phase and five cases in Group I and II underwent surgery in the chronic phase, but only one case of Group IIIR required surgery. Six cases of IMH required surgery. The rates of freedom from operation at four years was 25%, 21% and 83% respectively (<i>p</i>=0.07). Essentially, Stanford type A dissection should be treated surgically even though the false lumen is thrombosed. However, in the case of retrograde dissection accompanied by an entry in the descending aorta, medical treatment may be a strategy option.
ABSTRACT
Mitral regurgitation caused by papillary muscle rupture has a poor prognosis and should be operated on soon after onset. We recently encountered a patient who was operated on 8 months after the onset of mitral regurgitation caused by rupture of the posterior papillary muscle. The patient was a 72-year-old man who was admitted as an emergency case for acute left heart failure due to severe mitral regurgitation. As medical treatment was effective, he refused to have mitral valve surgery. Six months later, he was admitted to our hospital complaining of nocturnal orthopnea and underwent surgical treatment. Severe mitral regurgitation with postero-medial papillary muscle rupture was revealed by transesophageal echocardiography. Coronary angiography showed 90% stenosis of the proximal left circumflex artery. At 8 months after the onset of mitral regurgitation, the patient underwent successful scheduled mitral valve replacement together with coronary artery bypass grafting. There are few reports of mitral valve surgery being performed successfully for papillary muscle rupture due to coronary artery disease in the chronic stage.
ABSTRACT
Persistent sciatic artery is an embryonic blood vessel that continues to feed the lower extremity after fulfilling an important role in lower limb development during early gestation. It is so rare that only 20 cases have been reported in Japan. This paper describes a case of acute occlusion of a persistent sciatic artey. A 78-year-old woman was admitted to hospital because of sudden onset of severe pain in her left leg. Angiography showed bilateral persistant sciatic arteries (complete type) with occlusion of the left artery and a small aneurysm on the right side. Left femoro-popliteal bypass was performed and postoperative angiography showed that the graft was patent.
ABSTRACT
We report an alternative way to preserve autologous blood with the aid of erythropoietin for a patient with anemia combined with irregular antibody who need the CABG operation. A 62-year-old woman was given a diagnosis of angina pectoris due to three-vessel coronary artery disease. All blood reserved for the coronary operation was incompatible on the crossmatch test and an irregular antibody was suspected. Antibody screening tests revealed anti-drug antibody and anti-P1 antibody. The operation was postponed because she had anemia. After 800ml of autologous blood was collected with administration of erythropoietin and iron for a month, the operation was performed. Two saphenous vein grafts were anastomosed to the left anterior descending artery and circumflex branch respectively. Total blood loss was 580g. Her postoperative course was uneventful and hemoglobin level was ranged from 7 to 10g/dl without any homologous blood transfusion.
ABSTRACT
We report a 69-year-old woman with transient mitral valve regurgitation and hemolysis following mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. She had a history of congestive heart failure caused by mitral valve regurgitation so we performed mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis (Model 6900). Three days after surgery, a systolic murmur became clearly audible and the serum LDH level reached a maximum of 2, 018IU/<i>l</i> on postoperative day 10. Echocardiography showed regurgitant flow through the center of the bioprosthetic valve. It was thought that stent distortion of the implanted pericardial bioprosthesis had occurred and re-operation would be necessary, but the regurgitant flow disappeared suddenly on postoperative day 12. If mitral valve regurgitation occurs following mitral valve replacement with a pericardial bioprosthesis, stent distortion should be taken into consideration.
ABSTRACT
A 70-year-old man with a diagnosis of unstable angina pectoris (UAP) and arteriosclerosis obliterans (ASO) was admitted to our hospital with chest pain and intermittent claudication of both lower extremities. Coronary artery bypass grafting (CABG) was performed prior to peripheral arterial reconstruction due to UAP. He was in good condition after CABG, but he had sharp pain in both lower extremities suddenly on the 2nd postoperative day and the creatinine phosphokinase level increased to 17, 560IU/<i>l</i>. On the 3rd postoperative day axillo-bifemoral bypass was performed. However 5 hours after the revascularization, respiratory arrest and ventricular fibrillation occurred and he died in spite of attempted cardiopulmonary resuscitation.
ABSTRACT
The sudden development of cyanotic lesions on the foot and toes may be a result of atheroembolic disease referred to as “blue toe syndrome”. During the last 7 years, 10 patients, consisting of 7 men and 3 women, were treated for ischemia of the toes of varied severity. The patients' ages ranged from 58 to 85 years (mean 73 years). Five patients had lesions on both legs and 5 on one leg. Contrast-enhanced abdominal CT scan revealed atherosclerotic changes of the abdominal aorta concomitant with intramural thrombus in every examined case. Four patients were treated medically and 4 underwent surgery consisting of replacement of the abdominal aorta in 3 and minor amputation of the toes in the other case. Two other patients developed acute renal failure within two months after the diagnosis of blue toe syndrome and succumbed to either heart failure or bleeding peptic ulcer. Contrast-enhanced CT scan is important for the diagnosis of blue toe syndrome. Though the prognosis of patients with blue toe syndrome is good in most cases, multiple microembolization to the viscera may cause renal failure and the prognosis of those patients is less favorable. Surgical intervention should be considered if the blue toe syndrome patient has an abdominal aortic aneurysm or history of multiple embolic episodes.
ABSTRACT
A 65-year-old man was referred to our service complaining of intermittent claudication of his left leg. During preoperative examinations, he was found to have bilateral isolated internal iliac artery aneurysms. As it was strongly suspected that ischemic colitis or gluteal ischemia would be caused if his bilateral internal iliac arteries were ligated during aneurysm surgery, his right internal iliac artery was reconstructed using a prosthetic graft. His postoperative course was uneventful. As aneurysm of the internal iliac artery is rare, there are few reports about reconstruction of the internal iliac artery. Technical details and pitfalls of internal iliac artery aneurysm surgery were discussed.
ABSTRACT
A 55-year-old female with silent myocardial ischemia was admitted to our hospital for CABG. Her postoperative course was uneventful. However, after the initiation of oral nutrient intake on the first postoperative day, drainage from the anterior mediastinum increased to 600ml/day. The character of the fluid was milky and biochemical examination revealed that it had a high triglyceride content (925mg/dl). The patient was placed on a medium-chain triglyceride diet and intravenous hyperalimentation without success. On the sixth postoperative day, the mediastinum of the patient was re-explored. The fistula was located in the left side of the anterior mediastinum where the thymic tissue is located. The fistula was ligated and the chylorrhea ceased. The incidence of chylothorax after cardiac procedures through median sternotomy is rare. We recommend early surgical ligation of the fistula if the postoperative hemodynamic state of the patient is stable.
ABSTRACT
A 42-year-old female was admitted complaining of a pulsating mass of her left upper arm for two years. As she had played volleyball, she hit a ball with her upper arm accidentally for many times. The arteriogram showed a 30×35mm sized brachial artery aneurysm. Replacement of brachial aneurysm with saphanous vein graft was performed. Histologically, the aneurysmal wall consisted of three layers of arterial wall and had multiple breaks in continuity of the elastic layer. We diagnosed it was a true traumatic aneurysm caused by repetitive blunt injury. The causes and etiology of the brachial artery aneurysms were discussed.