ABSTRACT
We present a case of a 76-year-old woman who was diagnosed with sarcoidosis due to enlarged hilar lymph nodes 6 year earlier. Computed tomography (CT) revealed asymptomatic Stanford type A dissection at that time. A chest radiograph taken a year ago showed obvious cardiac enlargement; therefore, echocardiography was performed for further investigation, which revealed severe aortic regurgitation. The patient was referred to our department for surgery after the contrast-enhanced CT revealed the same intra-aortic intimal flap as before. Transthoracic echocardiography showed cardiac enlargement with a left ventricular end-diastolic diameter of 61 mm and aortic regurgitation of 3/4 degree. Contrast-enhanced CT showed an approximately 3-mm-wide band-like structure (linear shadow) that appeared to be the intima of the ascending aorta; however, no entry or false lumen was apparent. The structure in the ascending aorta had an appearance distinct from that of a typical aortic dissection, but was deemed possible in chronic aortic dissection. Nevertheless, intraoperative findings revealed that the linear shadow shown on CT was not due to dissection. The band-like structure was actually the intima, and it was excised. The aortic valve was replaced with a biological valve and the ascending aorta was replaced with a prosthetic graft. She was discharged home on the 11th postoperative day after a favorable recovery. Pathological findings of the band-like structure revealed the intima of the blood vessel and no evidence of inflammatory cell infiltration. There was no evidence of aortic dissection. We encountered a rare case of intra-aortic intimal band that was misdiagnosed and treated as an aortic pseudodissection. It is difficult to rule out aortic dissection prior to surgery; therefore, it is preferable to prepare the operation as a dissection.
ABSTRACT
Man in his 70s, who had suffered from idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital with chest pain at rest. Coronary angiography revealed obstruction of the right coronary artery and triple vessel disease. Because a bleeding tendency was expected during coronary artery bypass grafting, we performed percutaneous coronary intervention to the culprit lesion first, and then intravenous immunoglobulin and high dose dexamethasone were tried. His platelet count rose from 49,000 to 103,000/mm3, so we performed coronary artery bypass grafting. The patient had no postoperative hemorrhagic complications. We believe that high dose dexamethasone therapy is useful for patients with ITP who need surgery immediately.
ABSTRACT
A 52 year-old man was admitted to our institution with sudden onset of severe chest and back pain. The electrocardiogram showed ST segment depression in leads I, II, aVL, aVF, V3-6. Emergent coronary angiogram was performed, but the catheter did not reach to the coronary ostia, and it only performed false lumen aortogram. Computed tomography showed acute Stanford A aortic dissection. Ultrasound echocardiography also showed aortic regurgitation 3/4 degree. We decided to perform an emergency operation. During anesthesia induction, systemic blood pressure fell below 80 mmHg during systolic period, and pulmonary pressure raised to 60 mmHg. Transesophageal echography showed the movements of dissection flap intermittently obstructed the coronary blood flow and aortic valve annuls. Those flap movements, so called ‘flap suffocation’ was thought to be the cause of cardiac failure. Intra-operative findings of the ascending aorta showed an entry of dissection just above the left coronary ostia, and the entire detachment of intima to aortic wall. We performed ascending aorta replacement with aortic valve resuspension and fixation of coronary ostia. The postoperative course was uneventful, and he was discharged on the 25th postoperative day. For the precise treatment of acute Stanford A aortic dissection with such coronary ischemia, quick diagnosis and operative correction is essential.
ABSTRACT
A 64-year-old woman who had been followed for complete right bundle branch block at another hospital was found to have heart failure due to cardiac sarcoidosis. She was admitted because of progressive thinning of the ventricular septum and septal aneurysm which protruded into the right ventricle. On echocardiogram, her left ventricular ejection fraction had decreased to 40%. We decided to perform an operation because the patients's heart failure was thought to be due to dyskinesia of the ventricular septum with bulging of the septum into the right ventricle during systole, which consequently decreased cardiac output. The scarred ventricular septum, which was observed through right atrial, right ventricular and aortic incisions, was incised along the marginal normal interventricular myocardium. A tailored 4×3 cm oval Dacron patch was secured over this opening. A DDD pacemaker was implanted for complete atrio-ventricular block and, to synchronize both ventricles, ventricular leads were fixed on the right and left ventricular epicardium. Her postoperative course was uneventful. A postoperative pathologic study revealed a noncaseating granuloma on the border of the normal myocardium. We report a rare surgically treated case of cardiac sarcoidosis.
ABSTRACT
Thromboembolic events after cardiac surgery, including ischemic strokes, can be devastating complications, however only a few studies manifest the platelet activation and coagulation state after off-pump coronary artery bypass (OPCAB). Platelet-derived microparticles (PMP) are observed as released vesicles from platelets following platelet activation, and are believed to play a role in some clinical diseases because of their procoagulant activity. The aim of the present study was to evaluate the hypercoagulant state after OPCAB using PMP and other indices. Data were obtained from 15 patients (aged 69±7 years; only men) undergoing elective OPCAB surgery. One hundred milligrams of aspirin were used as postoperative antiplatelet drugs. Preoperative risk factors, operation time, postoperative hospital stay, transfusion and blood samples of CBC, PMP, βTG, PF 4, platelet aggregation, FDP, D-dimer and TAT of pre- and postoperative days (POD) 3 and 7 were studied. There was no difference between the PMP level with or without risk factor. The PMP levels of POD 3 and 7 were significantly higher compared to the preoperative levels (pre-op, POD 3, 7:9.1±5.1, 15.2±10.3, 28.4±24.5/10<sup>4</sup>plt respectively, <i>p</i><0.05). The levels of FDP, D-dimer and TAT rose significantly on POD 3 and 7 and significantly correlated with the PMP levels. Beta TG, PF 4 and platelet aggregation did not change after OPCAB surgery, and no correlation was found with the PMP levels. Elevated levels of PMP, TAT, FDP and D-dimer persisted until POD 7 and suggested not only platelet activation, but also activation of the coagulation and fibrinolytic system. The findings suggest that 100mg of aspirin may not be adequate for the inhibition of platelet activation after OPCAB surgery.