Résumé
A 59-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) had been treated by β-blocker for 15 years. Since June 2001 the patient has had symptoms of heart failure on sudden onset. Transesophageal echocardiography showed ruptured mitral chordae tendineae. After medical treatment to improve heart failure, open heart surgery was performed and anterior and posterior ruptured mitral chordae tendineae were recognized. Prosthetic valve replacement was performed. Histopathologic diagnosis of the chordae tendineae was myxoid degeneration. The postoperative course was excellent. Echocardiogram demonstrated that the preoperative left ventricular pressure gradient of 55mmHg reduced to 0mmHg postoperatively, which indicated that the left ventricular outlet stenosis had disappeared. In patients with HOCM accompanied by ruptured mitral chordae tendineae, early diagnosis by transesophageal echocardiography and timely surgical treatment are essential for successful outcome.
Résumé
During a 9-year period from January 1991 through December 2000, 30 patients underwent surgical interventions for peripheral vascular injuries associated with catheterizations. Pseudoaneurysm, the most frequent complication, was seen in 19 patients (63.3%). This was followed by arteriovenous fistula in 6 patients (20%), uncontrolled hemorrhage in three (10%), arterial thrombosis in one (3.3%), and pseudoaneurysm complicated with arteriovenous fistula in one patient (3.3%). We performed repair of the puncture site in 26 patients (86.6%), followed by arterial ligation in two (6.6%), thrombectomy combined with percutaneous transluminal angioplasty and aneurysmectomy in one patient (3.3%) respectively. There was a tendency for patients to have diabetes mellitus or hypertension. Though secondary suture had to be performed in two patients with wound infection postoperatively, there was no other complication. In pseudoaneurysmal patients proximal arterial control followed by direct incision into the aneurysm cavity and tangential finger pressure over the hole in the artery was a safe method to control bleeding. In arteriovenous fistula patients aggressive repair resulted in good outcome. In uncontrolled hemorrhage and arterial thrombosis patients prompt intervention is essential. By using accurate techniques in arterial puncture and adequate arterial compression following removal of the catheter, the incidence of vascular injuries can be reduced.
Résumé
A 40-year-old man was admitted because of prolonged fever after extraction of teeth. Infective endocarditis, congestive heart failure and hepatorenal failure were diagnosed in a series of examinations. Electrocardiograms showed complete atrio-ventricular block and QT prolongation. After continuous hemodiafiltration (CHDF) and high doses of antimicrobials promptly initiated for the treatment of multiple organ failure, the aortic valve with regurgitation and vegetation was replaced with an artificial valve. Serious arrhythmias occurred after the operation, which disappeared by the administration of antiarrhythmic agents. In cases of infective endocarditis with multiple organ failure, preoperative intensive treatment such as CHDF in combination with high doses of antimicrobials and surgical intervention represent a good strategy for successful outcome.
Résumé
A 32-year-old man was admitted with dyspnea on exertion and a prolonged common cold. Swelling of mediastinal lymph nodes, pericardial thickening and pleural effusion were detected by chest CT. Mycobacterial culture of sputa and pleural effusion were negative. Serum adenosine deaminase (ADA) activity was normal. A tuberculin test showed a positive reaction (20×15mm). Viral antibody titers (Coxsackie A9, echo 3, influenza B) were negative. Ten days after admission, the patient had pyrexia and low cardiac output symptoms. Right ventricular pressure curve cardiac catherterization showed a“dip and plateau”pattern which indicated constrictive pericarditis. We performed subtotal pericardiectomy (from the right phrenic nerve to the left phrenic nerve). Pathological examination of pericardium showed Langerhans' giant cell infiltration and caseous necrosis which could be diagnosed as tuberculosis. Although the patient had transient pleural effusion, symptoms disappeared postoperatively. At present there are no signs of recurrent infection.
Résumé
Single administration of warfarin at 0.1mg/kg was carried out at an early stage after cardiac operation, and changes in the blood vitamin K levels, blood coagulation factors and the blood warfarin levels within 24 hours of administration were evaluated to determine an ideal mode of initiating the administration and the initial dose in warfarin therapy at an early postoperative stage. The study group consisted of 30 postoperative cardiac cases, and 20 healthy individuals as controls. The results showed that anticoagulant effects cause close to the therapeutic range within 24 hours of administration of oral warfarin therapy in prothrombin time of the postoperative cases. As regards the blood vitamin K levels, both vitamin K<sub>1</sub> and K<sub>2</sub> levels were more depressed in the subjects than in the control group. Differences in the vitamin K level seemed to play a key role in the difference in anticoagulability between the two groups. It was thus implied that the risk of an abrupt decline in coagulability and a decrease in the level of vitamin K parallels the starting level of warfarin instituted in the wake of a cardiac operation. To conclude, safe and effective warfarin therapy should be started at a 0.1mg/kg dosage level at an early stage after the cardiac operation.