Résumé
Background: Pericardial effusion is a common finding with a wide spectrum of etiologies. Surgical management is recommended for a patient with intractable pericardial effusion which is resistant to medical treatment and causes cardiac tamponade. Various surgical approaches for pericardial effusion have been reported, for example thoracotomy, open abdominal surgery, video-assisted thoracic surgery, laparoscopic surgery, and subxiphoid approach. Objectives: We report the results of pericardial-peritoneal window using a subxiphoid approach under local anesthesia for refractory pericardial effusions. Methods: Five patients who underwent pericardial-peritoneal window surgery for refractory pericardial effusion between April 2011 to June 2022 were included in this study. The age of the patients was 61±14 years, and one (20%) was male. The comorbidities were four cases of autoimmune disease (two cases of scleroderma, one case of systemic lupus erythematosus, and one case of IgG4-related disease) (80%) and two cases of follicular lymphoma (40%). For comorbidities, steroids were administered in 2 patients (40%) and immunosuppressive drugs in 4 patients (80%). Colchicine was administered in 3 patients (60%) to treat pericardial effusions. Pericardiocentesis had been performed in 4 patients (80%) prior to surgery. Under local anesthesia in the supine position, a small incision was made at lower end of the sternum and the xiphoid process was resected. A pericardial-peritoneal window of more than 40 mm in diameter was created. In the past, only the diaphragmatic window was opened, but recently the diaphragmatic window and the anterior aspect of the pericardial sac membrane have been resected continuously to open the pericardial sac widely. Results: The operative time was 36±15 min. One complication was postoperative hemorrhage. There were no operative deaths or hospital deaths. Preoperative colchicine was discontinued in all patients after surgery. The mean postoperative follow-up was 2.7 years (0.5-5.9）, and no reaccumulation of pericardial effusion was observed in any of the patients. Conclusions: The pericardial-peritoneal window with a subxiphoid approach can be safely performed under local anesthesia, and if the window is created large enough, it could be a minimally invasive and effective treatment for refractory pericardial effusions.
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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.
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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.
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Lately, there has been a trend towards integration among cardiovascular surgery institutions. However, local institutions continue to play a crucial role in community-based medicine, given the emergent nature of cardiovascular diseases and the challenges involved in transporting patients with such conditions over long distances. We present the results of a questionnaire survey we conducted to examine the current status and issues faced by cardiovascular surgery institutions in community-based medicine.
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The Japanese board of cardiovascular surgery has changed the requirements for the certification of cardiovascular surgeons. The requirements include Off the Job Training and the training of extracorporeal circulation. The role of training facilities should be changed because of its duty. We showed a questionnaire survey about the new requirements for young cardiovascular surgeons in Hokkaido. We hope this article shows what is required for the training facilities in the new era.
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Left ventricular overlapping operation was applied to a woman with cardiac sarcoidosis who presented with cardiopulmonary arrest. She did not have any particular history, with minimal risk factors for atherosclerosis. By-stander cardiopulmonary resuscitation delivered by her husband saved her life. Acute coronary syndrome was denied by emergency coronary arteriography. However, left vetriculography revealed broad dyskinetic area inconsistent with coronary distribution. Those findings raised a high suspicion of cardiac sarcoidosis, although this was unconfirmed. Broad ventricular aneurysm and a history of cardiac arrest and congestive heart failure prompted us to operate on her. Left ventricular overlapping operation was applied followed by ICD implantation and steroid induction. The pathologic examination of the ventricular wall showed noncaseous epithelioid granulomas and polynuclear giant cells, which are consistent with cardiac sarcoidosis. She has been leading a healthy daily life without signs of heart failure for one and a half years after discharge. Lesions of cardiac sarcoidosis have a broad spectrum from narrow localized to wide generalized aneurysm. Appropriate surgical strategy should be performed according to the location and the extent of the lesion. Left ventricular overlapping operation is among the alternatives.