A Case Which Presented Morbidity Considered to Be Anaphylactoid Purpura after Thoracic Endovascular Aortic Repair / 日本心臓血管外科学会雑誌

We herein report a 79-year-old man who developed anaphylactoid purpura after thoracic endovascular aortic repair, which he underwent for a distal aortic arch aneurysm of saccular type. On the third postoperative day he had purpura over his lower legs and abdomen accompanied by intermittent fever. His serum C-reactive protein concentration reached a maximum of 12 mg/dl, and remained at around 4 mg/dl thereafter. A dermatologist diagnosed anaphylactoid purpura ; this gradually improved with topical steroid and the nature and dosage of the oral medication. We suspected the presence of malignancy ; however, appropriate investigations failed to identify a cause for the purpura. During 6 months of outpatient follow up he has been free of recurrence. Anaphylactoid purpura occurs most frequently in childhood, often after an upper respiratory tract infection, whereas this condition is rare in adults. Triggers for anaphylactoid purpura include surgery, infection, certain medications, chronic lung, liver, or renal failure, and malignancy. We believe that the stress of undergoing thoracic endovascular aortic repair was the trigger in this case. Anaphylactoid purpura may be complicated by arthritis, gastrointestinal involvement and renal manifestations. There were no such complications in this case.

A Case of Aortic Valve Replacement after Long-Term Antifungal Treatment of Candidemia / 日本心臓血管外科学会雑誌

We report a patient with candidemia, and remote organ infection, who underwent surgical treatment of aortic valvular stenosis. The patient was a 77-year-old man. <i>Candida glabrata </i>was detected in a blood culture during pharmacological treatment for pyelonephritis associated with vesicoureteral transition stenosis. A ureteral stent had been placed to preserve urine outflow, and vesicoureteral surgery had been scheduled. However, the urological surgery had to be performed first because of severe aortic valvular stenosis. After long-term (5 months) of antifungal treatment, <i>Candida </i>was no longer detected in the urine or blood cultures, but the serum <i>β</i>-D-glucan level did not fall below the reference value (21.6 pg/ml at the last measurement). It was difficult to control the infection further, and we decided to perform aortic valve replacement. There was no evidence of endocarditis at surgery, but pathological examination revealed traces of the fungus in the tissue of the aortic valve. The post-operative course was uneventful, and urological surgery was carried out 45 days later. Infection recurred when the antifungal medication was temporarily discontinued. The infection was then controlled by resumption of the antifungal medication. The patient has been free of recurrence for the past year since the aortic valve replacement. In the present case, in which a mycosis from a remote source was not readily eradicated prior to valve replacement, we were able to obtain good results by first administering long-term antifungal medication to quell the inflammation as much as possible.

A Novel Strategy with Fasudil, a Rho-kinase Inhibitor for Intractable Perioperative Myocardial Ischemia with Coronary Spasm / 日本心臓血管外科学会雑誌

We experienced 6 cases of intractable perioperative myocardial ischemia with coronary spasm that was successfully treated with fasudil, a Rho-kinase inhibitor. Three of the patients (aged 49-81 years) showed ST elevation on electrocardiograms and abrupt circulatory collapse after off-pump coronary artery bypass grafting. Emergeny coronary angiogram revealed severe spasm of their own coronary arteries and/or bypass grafts. Since intracoronary and/or intragraft injection of isosorbide dinitrate (ISDN) was ineffective, we administered fasudil into the spastic vessels, and that completely resolved the spasm. The other 3 patients (aged 55-77 years) suffered myocardial ischemia during the operation, though intravenous vasodilators including ISDN, diltiazem and nicorandil had been administered continuously. Their ischemia occurred when the aorta was declamped, the pericardium opened, or the bypass graft was anastomosed, respectively. We decided to use fasudil in these cases since ISDN was ineffective, or severe spasm was found on intraoperative inspection. Administration of fasudil successfully relieved the ischemia, and subsequently all 3 patients could be weaned from the cardiopulmonary bypass during the operation. Fasudil completely resolved the myocardial ischemia in all 6 patients. In conclusion, fasudil, a Rho-kinase inhibitor, is a useful agent for perioperative myocardial ischemia including coronary spasm that is resistant to intensive conventional vasodilator therapy. We should administer fasudil and relieve spasms as early as possible to rescue patients with intractable ischemia.