ABSTRACT
A 79-year-old woman, who had undergone mitral valve replacement with a Björk-Shiley valve 16 years previously, was transferred to our institute due to active prosthetic valve infection associated with severe heart failure on respirator. On admission, her white blood cells and c-reactive protein (CRP) were elevated to 15,700/µl and 7.29 mg/dl, respectively, and she had anemia (hemoglobine 8.1 g/dl), thrombocytopenia (platelets 75,000/µl), and renal dysfunction (blood urea nitrogen 57 mg/dl, creatinine 1.8 mg/dl, estimated glomerular filtration rate 21.5 ml/min/1.73 m<sup>2</sup>). Her brain natriuretic peptide was elevated to 456.7 pg/dl. Blood culture revealed bacteremia with <i>Streptococcus agalactiae</i>. Though CT scan revealed cerebellum infarction, we decided to perform emergency surgery because of uncontrollable infection and heart failure, even with massive infusion of catecholamine and respiratory support. At surgery, huge vegetation proliferated over the prosthetic valve. The prosthetic valve was detached from approximately two-thirds of the annulus due to an annular abscess. The infected annulus was resected aggressively. Mitral annulus was reconstructed and reinforced with a bovine pericardial patch, and the bioprosthetic valve of 23 mm in size was implanted in an intra-annular position. In the postoperative phase, antibiotics (ampicillin, gentamicin) was given, and CRP became negative 47 days postoperatively, and the patient discharged from the hospital 56 days after the operation.
ABSTRACT
<b>Objective</b> : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. <b>Methods</b> : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. <b>Results</b> : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m<sup>2</sup> (range : 1.00-1.92 m<sup>2</sup>). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. <b>Conclusions</b> : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.
ABSTRACT
The patient was a 39 -year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5, 99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery(segment 5, 100%), circumflex artery (segment 11, 99%), and right coronary artery (segment 1, 90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.
ABSTRACT
A 76-year-old woman presented because of bilateral lower-extremity edema and dyspnea. Transthoracic echocardiography revealed a mobile mass in the right atrium. A right atrial mass associated with heart failure was diagnosed. Surgery was performed. Intraoperative transesophageal echocardiography showed that the mass was contiguous with the inferior vena cava. However, the primary lesion was unclear. Therefore, only the intracardiac mass was resected. The margins of the residual tumor were marked with clips. Computed tomography performed immediately after surgery revealed a clip in structures contiguous with the region from a uterine myoma to the inferior vena cava. Intravenous leiomyomatosis was diagnosed on histopathological examination of the resected specimens. Computed tomography 6 months after surgery showed that the clip had moved from the inferior vena cava to a vein contiguous with the uterus. The tumor regressed slightly. Close follow-up is required.
ABSTRACT
A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.
ABSTRACT
A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.
ABSTRACT
A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.
ABSTRACT
A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed <i>Staphylococcus aureus</i>. A mycotic pseudoaneu-rysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.
ABSTRACT
In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (<i>p</i>=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (<i>p</i>=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (<i>p</i>=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (<i>p</i>=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (<i>p</i>=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (<i>p</i>=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (<i>p</i>=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.
ABSTRACT
A 61-year-old woman was admitted with abdominal and low back pain. The patient underwent graft replacement for inflammatory abdominal aortic aneurysm. One month postoperatively, the patient fell into hypovolemic shock with massive melena and hematemesis. Laparotomy and duodenotomy revealed a fistula between the third portion of the duodenum and the distal anastomosis of the vascular prosthesis. The fistula of the aorta was repaired with omentopexy, gastrojejunostomy and Braun's anastomosis. One month later, aortoduodenal fistula recurred. The vascular prosthesis was partially removed and the aorta was closed at the infrarenal level. After the closure of the posterior duodenal defect, a left axillo-femoral bypass was constructed. She fully recovered and discharged.
ABSTRACT
Fourteen patients with 22 solitary aneurysms of the iliac artery were operated in a 16-year period (1983 to 1999). Patients were divided into two groups. The non-ruptured group consisted of 6 patients who underwent surgical intervention before aneurysm rupture, and their mean age was 78.5 years. The ruptured group consisted of 8 patients who underwent surgical intervention for aneurysm rupture, with a mean age of 68.5 years. Although seven patients underwent emergency surgery for aneurysm rupture, less than half of them were operated upon within 24hr after the onset of aneurysm rupture. The average size of aneurysms was similar in the two groups (common iliac artery aneurysms: non-ruptured 47mm vs. ruptured 44mm in diameter, internal iliac artery aneurysms: non-ruptured 55mm vs. ruptured 55mm). Two patients died in the ruptured group, in which the operative mortality rate was 25%. Six patients (75%) of the ruptured group had hypovolemic shock, and two of them died during surgical repair. Of the patients with shock, two patients had intestinal ischemia after operation. Intestinal ischemia was one of the serious complications of ruptured iliac aneurysms. These results suggest that in patients with shock from ruptured iliac artery aneurysms, strategy for treatment is an important determinant of the outcome.
ABSTRACT
The purpose of this study was to consider the cause of the prolonged inflammatory reaction that sometimes appears after endovascular stent-graft repair for dissecting aortic aneurysm. Endovascular stent-grafting was performed in 12 patients (11 men and 1 woman, mean age 60±9.8). Endovascular stent-grafting was indicated to close the entry of type B dissections in 10 patients and to exclude ulcer-like projections (ULP) in 2 patients. On the 7th postoperative day (POD), aortography showed no endoleak in 7 type B cases (A-group), remaining endoleak in 3 type B cases (B-group), and complete exclusion in 2 ULP cases (C-group). The value of FDP-E in the A-group was high on the first POD and then decreased gradually. FDP-E also increased up to the 7th POD in the B-group, and increased very slightly after the operation in the C-group. The values of WBC and CRP increased up to the 3rd POD in all groups, but in the A-group it was still high on the 7th POD. On contrast-enhanced CT performed after the procedure and on the 7th POD, edema (over 10mm in thickness) around the descending thoracic aorta was demonstrated in 5 out of 7 cases in the A-group, but in none of the cases in the B- and C-groups. A segmental atelectasis in the left lung was detected in 6 out of 7 cases in the A-group, but in none of the cases in the Band C-groups. In the A-group, endovascular stent-grafting influenced thrombus formation, and the thickened edema around the descending thoracic aorta and the atelectasis produced in the left lung were prominent more than in the other groups. These results suggest that the Inflammation around aortic wall induced by thrombosis in the false lumen, might contribute to the development of the edema around the descending thoracic aorta and the atelectasis in the left lung. We conclude that the inflammatory reaction might have prolonged the postoperative course in the A-group patients.
ABSTRACT
A 51-year-old man underwent arch replacement for a thoracic aortic succular aneurysm in December 1996. The pathological examination indicated aortitis to be the cause of the aneurysm. At that time we did not surgically treat the abdominal aortic aneurysm (AAA) which was only 32mm in diameter. Sixteen months after the first operation, he complained of a pulsatile tumor in his left leg. Angiography revealed an aneurysm of the left superficial femoral artery. The artery distal to the aneurysm was occluded, and the left popliteal artery received collateral blood flow from the deep femoral artery. The size of the AAA increased to 48mm, an indication of repair. Aneurysmectomy of the left superficial femoral artery and replacement of the abdominal aorta were performed simultaneously. The operative findings showed that the aneurysm of the left superficial femoral artery had been ruptured and formed a pseudoaneurysm. The pathological findings demonstrated both aneurysm aortitis. After the second operation, he was given steroid therapy to control the inflammatory reaction and he has been well for one year.
ABSTRACT
A 49-year-old man who had no history of cardiac disease or intravenous drug abuse was referred to our hospital complaining of fever despite antibiotic chemotherapy. Blood culture was positive for <i>Streptococcus agalactiae</i>, and transesophageal echocardiography revealed vegetation attached to the tricuspid valve and moderate tricuspid regurgitation. Two-thirds of the anterior leaflet and a part of the posterior leaflet of the tricuspid valve were excised with the vegetation, and the remaining anterior leaflet was sutured to the posterior leaflet after annular plication. DeVega's annuloplasty was added to a diameter of two fingers. Following this procedure tricuspid regurgitation was minimal.
ABSTRACT
Although insulin resistance in peripheral tissue has been demonstrated in patients with cardiac disease, expression of glucose transporter (GLUT) isoform mRNA in the cardiac muscle is not known. We analyzed GLUT isoform mRNA in the cardiac muscle of 10 patients by RT-PCR. GLUT 4 mRNA was semi-quantitated by kinetic analysis, altering the cycles of PCR, and insulin resistance was examined by euglycemic hyperinsulinemic glucose clamp with an artificial pancreas. In addition to GLUT 2, 3, and 4 mRNA, all of which were constantly demonstrated in the skeletal muscle of normal volunteers, GLUT 1 was documented in all the cardiac samples examined. The quantity of GLUT4 mRNA was not related to the degree of insulin resistance or <i>M</i> values. These results may suggest that glucose uptake in the cardiac muscle is maintained by 4 different glucose transporters and that the response of GLUT 4 mRNA to insulin resistance is different in the cardiac muscle and in the skeletal muscle.
ABSTRACT
A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.
ABSTRACT
We studied the effects of granulocytic elastase (GEL) and fibronectin (FN) on the coagulation and fibrinolytic system when using cardiopulmonary bypass (CPB). Blood sampling was performed before CPB (Pre), just after CPB (Post) the 1st postoperative day (PD1) and the second postoperative day (PD2). Laboratory parameters were GEL, FN, fibrinogen (Fib), prothrombin time (PT), fibrin degradation products (FDP), D dimer (D-D), α2 plasmin inhibitor plasmin complex (PIC) and antithrombin III (AT III). The level of GEL was highest and that of FN was lowest at Post. The levels of Fib, PT and AT III were lowest and that of PIC was highest just after CPB. The levels of FDP and D-D were highest on PD1. The levels of GEL and D-D correlated just after CPB and on PD1 and PD2. The level of GEL correlated with that of PIC on PD1. These results demonstrated that the level of FN decreased with CPB. And it was expected that CPB time affected the level of GEL. The levels of GEL affects D-D and PIC which are fibrinolysic factors particularly related to secondary fibrinolysis.
ABSTRACT
We report a relatively rare case of syphilitic aortic aneurysm that was treated by reconstruction with interposition of a prosthesis. The patient was a 72-year-old woman who presented with an abnormal shadow on chest radiograph and an abdominal pulsatile tumor. Aortography revealed double aneurysms in the descending thoracic and infrarenal abdominal regions, combined with a left common iliac artery aneurysm. Microscopic examination revealed an inflammatory infiltrate within the adventitia and destruction of the elastic fibers in the media, classical features of syphilitic aortitis. The incidence of double aortic aneurysm is expected to increase in the future, and one of the many problems involved in the management of this disorder is the correct timing for safe surgery. We prefer simultaneous surgery to secondary surgery, since this rules out the possibility of rupture of the remaining aneurysm. In order to perform this operation safely, it is necessary to treat the patient's general condition with regard to the surgical procedure and possible adjevant therapy.
ABSTRACT
There were 16 patients who developed acute renal failure (ARF) follwing cardiovascular operation using extracorporeal circulation. They were treated by either CPD or CAVH because their ARF were resistant to medical treatment. These patients were divided into three groups according to their treatment; 7 patients treated by CPD (Group A), 5 patients treated both CPD and CAVH (Group B), 4 patients treated by CAVH (Group C). The survival rate was 33% in Group A, 20% in Group B, and 0% in Group C. The prognosis of the each group was poor. CPD and CAVH were effective to control the concentration of serum potasium and water removing. But CPD and CAVH were not very effective to control the concentrations of serum creatinine and blood urea nitrogen. There were three patients who developed low proteinemia which was one of the side effects of CPD. Seven of nine patients treated by CAVH, developed bleeding. The side effects of CAVH were seemed to be more severe than those of CPD.
ABSTRACT
This report documents a case of three-channeled aortic dissection. The diagnosis of dissecting aneurysm was made by chest X-P and CT to 70-year-old man, with a chief complaint of back pain. Aortogram showed aortic aneurysm (DeBakey type IIIb), which had an entry at distal of the beginning of the left subclavian artery. Though we had given a pressure control therapy, the patient died on the 5th day of the admission. At autopsy, a new dissection was found in the chronic dissecting outer wall, forming three channeled dissection and rupture was there. Three-channeled dissection is very rare, only 8 cases including ours have been reported so far. From this case, we learned it very difficult to diagnose and treat it.