ABSTRACT
We report a successful conversion of anti-coagulant therapy from warfarin to heparin for a case of mechanical heart valve and warfarin-induced skin ulcer. A 57-year-old female who was diagnosed with Ebstein disease and underwent mechanical valve replacement suffered from a recurring and resistant leg skin ulcer. Nine years after the induction of warfarin, her right leg skin ulcer occurred suddenly and worsened gradually. No dermatological treatment could cure it and three auto-skin transplantations were performed in the past four years. The definitive cause of the ulcer could not be diagnosed by any laboratory study or image inspection. Further, after every transplant surgery, the resumption of warfarin had made her ulcer recur and worsen. Therefore, we finally came to think of this disease as the warfarin-induced skin ulcer. To avoid warfarin, subcutaneous self-injection therapy of Heparin-Ca was applied as her anti-coagulation after the 4th transplant surgery. The patient was discharged from hospital on post-operative day 78 with a good condition of the transplanted skin graft and right leg. An adequate level of APTT could be maintained with injections of 10,000 units of Heparin-Ca twice a day and data on D Dimer and cardiac echography show no thromboembolism at the out-patient visits. The result of auto-skin transplantation is also a good course under this therapy. As we have very few reports concerning heparin self-injection therapy for artificial valves, it is very important that careful observation should be continued.
ABSTRACT
Isolated unilateral absence of the right pulmonary artery without any intracardiac anomaly is a rare congenital cardiovascular disorder. We performed a successful surgical reconstruction with autologous tissue of this anomaly. The patient was a 1-month-old boy who had been transferred to our center at 3 days of age because of tachypnea and heart murmur. Multi-detector CT and radial angiography imaging revealed isolated unilateral absence of the right pulmonary artery and left patent ductus arteriosus. Conservative treatment did not help his progressive heart failure and pulmonary hypertension due to an acute increase of pulmonary blood flow. Therefore surgical correction was determined to avoid the worsening of those symptoms. Under cardiopulmonary bypass, the right pulmonary artery branching off from the brachiocephalic artery was removed and anastomosed to the main pulmonary artery with an autologous pericardium roll. Symptoms improved postoperatively and he was discharged in good condition on the 21st of postoperative day. Cardiac catheterization, 3 months later, showed excellent results.
ABSTRACT
Scimitar syndrome is a rare congenital cardiac anomaly with anomalous right pulmonary veins draining to the inferior caval vein. Currently, it is widely accepted that there are 2 forms of presentation with either an infantile manifestation or an adult form. Patients in the latter category are usually less severely affected and frequently asymptomatic on diagnosis. A 16-year-old boy who had been given a diagnosis of scimitar syndrome was observed for years because of his unwillingness to undergo surgery. However, since the latest catheter examination demonstrated an elevated pulmonary-to-systemic flow ratio of 2.39, he consented to undergo surgical treatment. Preoperative studies demonstrated an intact atrial septum and abnormal bronchial arborization of the right lung. Pulmonary angiography demonstrated abnormal right pulmonary veins that converged to a single venous trunk, the so-called scimitar vein, and drained into the inferior caval vein at the level of diaphragma. Because of the morphological abnormalities including a wide distance between the pulmonary veno-caval junction and interatrial septum, counterclockwise rotation of the heart, and a small left atrium, surgical management was performed with a novel approach, consisting of relocation of the scimitar vein to the anterolateral wall of the right atrium, total excision of the oval fossa, and intra-atrial baffle rerouting with the pulmonary venous blood being conveyed to the left atrium through the atrial septal defect. During the cardiopulmonary bypass vacuum assisted venous drainage through a femoral venous cannula was highly effective to secure a clear operative field without occlusion of the inferior caval vein. Postoperative recovery was uneventful and the repeat Doppler echocardiography demonstrated an unobstructed flow through the baffle. This experience indicates that the above novel approach is a promising surgical option for the management of scimitar syndrome.
ABSTRACT
Pulmonary venous obstruction (PVO) after repair of total anomalous pulmonary venous connection remains a significant problem. Once it occurs, it not infrequently recurs. A 14-month-old boy with recurrent pulmonary venous obstruction after repair of mixed type total anomalous pulmonary venous connection was successfully treated by the method of sutureless <i>in situ</i> pericardial repair and anastomosis of the left pulmonary vein to the left atrial appendage. His postoperative course was uneventful. Cardiac catheterization at 2 years and 9 months after the re-redo operation showed successful relief of PVO with marked reduction of pulmonary hypertension. In addition, multidetector computed tomography (MDCT) performed 3 years and 1 month after the operation showed no pulmonary vein obstruction.
ABSTRACT
A 21-year-old man with coronary sinus atrial septal defect (ASD) was treated successfully. This case had been diagnosed as an ASD without a lower margin preoperatively but we confirmed this to be a coronary sinus ASD intraoperatively, and this case was classified as partially unroofed coronary sinus without PLSVC. The diagnosis of coronary sinus ASD before operation is sometimes difficult. Therefore we should pay attention to the location of the defect and the dilated coronary sinus in echocardiography, and the course of the cardiac catheter entering into the left atrium, for a correct diagnosis. In this case, the defect was located in the vicinity of the ostium of a large coronary sinus, therefore we could close the defect between the CS and the LA using a heart-shaped patch without any damage to the AV node.
ABSTRACT
Intermittent cold blood cardioplegia with retrograde coronary perfusion was demonstrated in 11 CABG cases and the effects of myocardial protections were compared with 11 cases of antegrade perfusion. We evaluated the effects from the assistant perfusion time after aortic declamping, the incidence of occurrence of spontaneous beating, the dose of catecholamin required after CPB, and the changes in myocardial enzyme values. The two groups were similar in age, ejection fractions, and the extent of coronary artery disease. There were no cases of death and no PMI in all 22 cases, and the mean number of grafts and aortic clamping time were similar in the two groups. Concerning the effects of myocardial protections, there were no significant differences in any items in the two groups. We conclude that intermittent cold blood cardioplegia with retrograde coronary perfusion provides the same myocardial protective effects as the antegrade perfusion in CABG cases.
ABSTRACT
A 56-year-old man with uncontrolled diabetis mellitus was admitted with general fatigue and high fever. Abdominal CT and aortography showed a saccular aneurysm in the left common illiac artery. Salmonella choleraesuis infection was diagnosed on the basis of blood culture. We performed a two-staged operation because of the tight inflammatory adhesions and the abcess formation around the aneurysm. First we performed surgical treatment of the aneurysm and extra-anatomical bypass grafting (F-F crossover bypass). Then the <i>in situ</i> graft replacement was performed, 4 weeks later. After the second surgery, antibiotics were administered for 6 more weeks. The patient remains asymptomatic for 6 months after the record operation.