Tricuspid Annuloplasty and Mitral Valvuloplasty for Tricuspid and Mitral Regurgitation with Severe Right Heart Failure Complicated with Liver Cirrhosis / 日本心臓血管外科学会雑誌

A 71-year-old woman underwent VVI pacemaker implantation for complete atrioventricular block 38 years ago at the cardiovascular department of another hospital. In the course of observation, she developed atrial fibrillation. One year ago, she was admitted to hospital for aggravated congestive heart failure and was subsequently treated by a cardiovascular practitioner. She had persistent shortness of breath and lower leg edema, which were treated with increasing doses of oral diuretics. Due to poor treatment outcomes, she was referred to our hospital. Her echocardiography results suggested severe tricuspid regurgitation (TR) and moderate mitral regurgitation. She was also found to have impaired renal function and liver cirrhosis (Stage A of the Child classification), and was admitted. In addition, she had undernutrition with suspected cardiac cachexia. She was first treated by inotrope infusion and central venous hyperalimentation before tricuspid annuloplasty and mitral valvuloplasty were performed. Even though her postoperative management was complicated, she was discharged from our hospital. The conservative treatment with the increased dose of the diuretic for TR-associated right heart failure was prolonged in this patient, leading to severe right heart failure and aggravation of impaired renal function or congestive liver-associated hepatic disorders. Eventually, the patient required operative intervention; however, postoperative management is usually complex, and the operation result may be poor in such patients. We suggest that, from the time when right heart failure can be managed with relatively small doses of diuretics, surgeons should be involved in the care of patients with severe TR who do not require left heart valvular surgery, and should discuss the necessity of surgery earlier than the relevant guidelines suggest, depending on the patient's condition.

A Case of Disseminated Intravascular Coagulation Complicating Thoracic Aortic Aneurysm for Which Recombinant Human Soluble Thrombomodulin Was Effective / 日本心臓血管外科学会雑誌

Chronic disseminated intravascular coagulation (DIC) complicates 5.7% of thoracic aortic aneurysm. DIC with thoracic aortic aneurysm is characterized by hyperfibrinolysis, but usually shows a stable condition in a state of compensated non-overt DIC with limited hemorrhagic symptoms. However, in some cases, hemorrhage caused by external factors may induce uncompensated overt DIC and lead to serious hemorrhagic tendencies. In the present study, we report a patient with a thoracic aortic aneurysm complicated by DIC who exhibited marked hemorrhagic tendencies. DIC remarkably improved following administration of recombinant human soluble thrombomodulin.

Impending Ruptured Abdominal Aortic Aneurysm in a Patient with Chronic Idiopathic Thrombocytopenic Purpura / 日本心臓血管外科学会雑誌

A 64-year-old man had been followed up under the diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), and infrarenal abdominal aortic aneurysm with a maximum diameter of 85mm since August in 1998. He suffered from sudden abdominal pain in August 1999, and as impending ruptured abdominal aortic aneurysm was diagnosed based on the CT findings showing left retroperitoneal hematoma and leakage of contrast medium from the aneurysm. We decided to perform elective surgery. Since he was not in shock and had a low platelet count (2.5×10⁴/mm³), medical treatment was indicated for hypertension and thrombocytopenia prior to surgery. High-dose immunogloblin infusion and platelet transfusion was begun two days before the operation and increased the platelet count to 6.1×10⁴/mm³, resulting in a successful elective operation.