Cardiac Tamponade due to Detachment of the Aortic Valve Commissure / 日本心臓血管外科学会雑誌

A 68-year-old man was taken to our hospital by ambulance due to syncope. He was in shock with cardiac tamponade. Pericardial drainage was performed. Aortic valve regurgitation gradually increased and surgery was performed at 25 days after onset. Surgical finding showed that there was a detachment of the commissure between the right and non coronary cusps of the aortic valve. An intimal tear was detected in the same place and aortic root replacement was required. The patient had a good recovery and he was discharged 14 days after surgery.

Ruptured Coronary Artery Aneurysm with a Fistulous Communication / 日本心臓血管外科学会雑誌

A 68-year-old woman was referred to our hospital with arrhythmia and cardiomegaly. She lost consciousness in the waiting room. After urgent hospitalization, cardiac ultrasonography showed cardiac tamponade, and urgent pericardial drainage was performed. A ruptured coronary aneurysm with a fistulous communication was diagnosed by CT scan and coronary angiography. Under extracorporeal circulation, ligation of the unusual coronary vessels and resection of the aneurysm were performed. The postoperative course was uneventful and she was discharged on the 25th postoperative day. No ischemic signs were observed on treadmill test at one year after surgery. Most congenital coronary aneurysms are asymptomatic; however, once rupture occurs, it is important to diagnose this condition rapidly and treat surgically.

Effects of Modified Ultrafiltration in Pediatric Cardiac Surgery / 日本心臓血管外科学会雑誌

Modified ultrafiltration (MUF) for cardiopulmonary bypass (CPB) in children decreases total body water and improves left heart function. We investigated the effects of MUF in pediatric open-heart surgery. Eighty-six patients less than 15kg who underwent radical cardiac operation were divided into four groups according to whether they received transfusion during the operation or not, and whether MUF was performed after completion of CPB or not. MUF group showed significantly higher hematocrit levels 20min after the end of CPB compared with non-MUF group in both transfused group and non-transfused group. Then, MUF group showed a significantly higher serum protein level than non-MUF group. In MUF groups, the systolic blood pressure elevated without the elevation of the left atrial pressure. We calculated PaO₂/FiO₂ as an index of postoperative lung function. The postoperative PaO₂/FiO₂ of MUF group was significantly higher than that of non-MUF group in transfused group. MUF significantly decreased homologous blood transfusion during the operation. MUF after CPB elevated hematocrit level and serum protein level, and improved cardiac function without volume load. Since MUF reduced the need for homologous blood transfusion. MUF is a useful means for pediatric cardiac surgery.

A Case of Catastrophic Pulmonary Bleeding That Occurred after Extensive graft Replacement of the Ascending, Transverse Aortic Arch and the Descending Thoracic Aorta / 日本心臓血管外科学会雑誌

This report describes 5 patients in whom extensive graft replacement was performed using a combination of median sternotomy with antero- or postero-lateral thoracotomy: 3 of them received replacement from the ascending to the descending thoracic aorta through the transverse aortic arch, and 2 of them received replacement from the transverse aortic arch to the descending thoracic aorta. Four of the 5 patients had catastrophic pulmonary bleeding during surgery and died immediately after the surgery. Histological investigations on 3 of the 5 patients revealed the presence of bleeding in bilateral alveola; edema in the pulmonary parenchymal tissues; and heavy bleeding extensively in the lung which was especially intensive in the pulmonary hilum and caused necrosis of that region in one case. We presume that long periods of total heparinization (extracorporeal circulation time>240min) performed during lateral thoracotomy, were the most important cause of the pulmonary bleeding. Other factors that could cause pulmonary bleeding are (i) avoidance of use of a double lumen endotracheal tube, (ii) pulmonary congestion due to heart failure during surgery, and (iii) pulmonary injury caused by surgical manipulation. We therefore consider that extensive graft replacement of the thoracic aorta through lateral thoracotomy using a pump-oxygenator, is associated with a high risk of pulmonary bleeding when it takes longer than 240min, and it is essential to perform the graft replacement in the possible shortest time.