Successful Treatment of a Chronic Pulmonary Thromboembolism Associated with Right Atrial Thrombus, Atrial Fibrillation and Tricuspid Insufficiency / 日本心臓血管外科学会雑誌

We describe an unusual case of a chronic pulmonary thromboembolism with right atrial thrombus. A 56-year-old man suffering from chronic pulmonary thromboembolism for 5 years complained of increasing dyspnea. Computed tomography revealed massive emboli in bilateral pulmonary arteries and a thrombus in the right atrium. Massive tricuspid regurgitation and atrial fibrillation were also recognized. We performed pulmonary thromboendarterectomy using a Jamieson rigid long miniature sucker with a rounded tip and our original flexible sucker under deep hypothermic circulatory arrest. Right atrial thrombectomy, tricuspid annuloplasty and a Maze procedure were also performed during the cooling, recirculating, and warming period. His postoperative cause was uneventful, and he was able to return to an ordinary lifestyle without acquiring oxygen inhalation. Tricuspid annuloplasty and Maze operation during pulmonary thromboendarterectomy contributed to the maintenance of stable homodynamics during and after surgery.

A Giant Right Atrial Myxoma with Lung Carcinoma Detected by Syncope / 日本心臓血管外科学会雑誌

A 75-year-old man was referred to our hospital with dyspnea on effort, recurrent attacks of loss of consciousness and abnormal shadow on chest X-ray film. Computed tomographic scan confirmed a 1.5×2.0cm mass with slight spiculation in the right lower lobe (S6) and revealed an ovoid right atrial mass. Transthoracic echocardiography showed that the giant mass which filled most of the right atrium had no mobility. Coronary angiography revealed clusters of new vessels which originated from the atrial branches of the circumflex coronary artery. A T1-weighted MRI scan demonstrated that the mass was isointense relative to the adjacent myocardium. We considered that performing cardiac surgery prior to pulmonary resection, as in a staged procedure, would have advantages in morbidity. We first performed removal of the right atrial tumor which was a 6.8×5.5×4.5cm shiny mass attached to the interatrial septum. Histological examination of the mass confirmed the diagnosis of cardiac myxoma. Three months later, right S⁶ segmentectomy was carried out using thoracoscopy and the tumor was finally diagnosed as squamous cell carcinoma. We have followed the patient for about 10 months after the first operation and there is no evidence of tumor recurrence and no more syncopic attacks.

A Case of Cardiac Infiltrating Lipoma in the Interatrial Septum / 日本心臓血管外科学会雑誌

A 75-year-old woman presented with chest pain on exertion. Cardiac catheterization revealed double vessel coronary artery disease. Echocardiographic examination showed the presence of an abnormal mass in the interatrial septum without any flow velocity signal within the mass. She was scheduled for elective coronary artery bypass grafting. The lesion appeared as a homogeneous mass on CT scan, with an attenuation coefficient of -122 Hounsfield units, suggestive of lipoma. A T1-weighted MRI scan demonstrated that the signal intensity of the interatrial mass corresponded to that of fatty tissue. On surgery with cardiopulmonary bypass a large mass was found to involve the right atrial wall, the interatrial sulcus and the interatrial septum. The mass could not be resected completely, because it adhered strongly to the septal myocardium. On histological examination, the tumor was composed of mature fatty tissues, was not encapsulated and was diagnosed as infiltrating lipoma. The postoperative course was uneventful. CT, MR imaging and color Doppler ultrasonography were very useful in making a tissue-specific diagnosis.

A Modified Procedure Using Branched Graft as Inflow for Leg Revascularization in a Case of Acute Type A Aortic Dissection Complicated with Leg Ischemia / 日本心臓血管外科学会雑誌

A 32-year-old man with severe back pain and cold, pulseless bilateral lower extremities was admitted. Enhanced CT scan revealed acute type A aortic dissection and the true lumen was severely compressed or occluded at the level of the abdominal aorta. Emergency simultaneous graft replacement of the ascending aorta and aortic arch was performed under deep hypothermic circulatory arrest, antegrade selective cerebral perfusion in addition to the elephant trunk technique. Although distal anastomosis was constructed only to the true lumen, leg ischemia persisted. Therefore, a new modified procedure applying a branched graft used for antegrade systemic perfusion as inflow and conventional axillo-bifemoral bypass graft was anastomosed to restore adequate circulation to the lower extremities. In the treatment of acute type A aortic dissection complicated with leg ischemia, the modified technique we employed is a simple and feasible method for leg revascularization in cases in which malperfusion to the leg persists in spite of complete of aortic repair.

A Case of Graft Duodenal Fistula Occurring after Operation for Thoracoabdominal Aortic Pseudoaneurysm Associated with Behcet's Disease / 日本心臓血管外科学会雑誌

A 41-year-old woman was given a diagnosis of Behçet's disease at age 25. When she was 31, a large aortic pseudoaneurysm developed near the left renal artery. Isolation of the aneurysm and anatomical grafting and ancillary bypass were performed. Ten years later, a graft duodenal fistula developed. Extra-anatomical reconstruction was done after complete resection of the original graft and the infectious lesion. It was found that the intra-abdominal organs were receiving blood supply only from the inferiol mesenteric artery. Moreover, severe ischemia of the intra-abdominal organs was a concern during surgery. Therefore, hepatic vein oxygen saturation was monitored continuously with a Swan-Ganz catheter for ischemia of the intra-abdominal organs. It proved to be a very effective indicator and we could perform this operation safely. Reoperation of grafting is often inevitable in patients with Behçet's disease. Also, two stumps of abdominal aorta were left in this patient because of the extra-anatomical reconstruction. Pseudoaneurysm may later occur at the site of the stumps, thus necessitating careful follow-up observations.

Clinical Tutorial System at Chiba University School of Medicine / 医学教育

Many institutions have applied a tutorial system to medical education since Tokyo Women's Medical College started doing so in 1990. Chiba University School of Medicine started a clinical tutorial system in April 1997 and has continued it for 4 years. Our system has employed problem-based learning using cases, with the goal of students' acquiring self-learning and problem-solving skills. This tutorial system has been positively evaluated by both students and instructors and is likely to be useful for clinical medical education.

A Case of Intravenous Leiomyomatosis Extending into the Right Ventricle through the Internal Iliac Vein and Inferior Vena Cava / 日本心臓血管外科学会雑誌

Intravenous leiomyomatosis (IVL) is defined as the extension into the venous channels of histologically benign smooth muscle tumors originating either from a uterine myoma or from the walls of a uterine vessel. We report a case of IVL extending to the right atrium and right ventricle through the right internal iliac vein and the inferior vena cava. The patient was a 43-year-old woman. The tumor was extirpated by simultaneous median sternotomy and laparotomy with the use of cardiopulmonary bypass. It was necessary to use cardiopulmonary bypass in order to open the right atrium. However, it proved difficult to insert the venous cannulae into the inferior vena cava due to the presence of the tumors. In order to perform the cannulation, a trans-right atrial excision of this tumor was necessary. Nevertheless, hemodynamic deterioration tended to occur during the procedure because of unexpected bleeding. We believe that to safely carry out this operation, it would be better to ensure circulatory arrest before trans-right atrial excision of the tumor. We have been continuing preventive antiestrogen therapy because recurrence would be very likely if any tumorous tissue remained after surgery. Fortunately, no intravenous infiltration of the tumor has been detected by either pelvic computed tomography or ultrasonography during the 26-month follow-up period. Surgical excision of the tumors and postoperative medication are now believed to have been effective.

A Case of a Solitary Aneurysm of the Left Common Iliac Artery Caused by Fibromuscular Dysplasia / 日本心臓血管外科学会雑誌

A 52-year-old man was referred to our institution because of a solitary aneurysm of the left common iliac artery. The presence of the aneurysm was demonstrated by CT and angiography. The aneurysm had a diameter of about 30mm. The walls of the bilateral external iliac arteries were irregular, like a string of beads. The aneurysm was resected and replaced with a vascular prosthesis. Histological examination of the aneurysm and a part of the left external iliac artery indicated a diagnosis compatible with fibromuscular dysplasia (FMD: medial fibroplasia). A solitary iliac aneurysm is rare, and is usually due to atherosclerosis. However, the aneurysm in this case was related to FMD. To the best of our knowledge, only one other case of a solitary common iliac aneurysm caused by FMD has so far been described.