Bilateral retroperitoneal approach to repairing a ruptured right iliac artery aneurysm in a patient who has undergone transperitoneal abdominal surgery.

An 84-year-old woman with a history of surgery for cholangiocarcinoma presented to Akita University Hospital with severe right lower abdominal pain, respiratory distress, and hypotension. Computed tomography scanning revealed a ruptured right common iliac artery aneurysm with a massive right retroperitoneal hematoma and a right internal iliac artery aneurysm. Under the bilateral retroperitoneal approach, we preformed an in-situ repair of an aneurysm rupture from the aorta to the left common and right external iliac arteries using a bifurcated knitted Dacron graft, and then we ligated the right internal iliac artery. The postoperative course of the patient was uneventful. The patient was discharged from hospital 52 days after surgery. In conclusion, a bilateral retroperitoneal approach may be a safe and useful strategy for in-situ repair of a right iliac artery aneurysm rupture in patients with peritoneal adhesions after transperitoneal abdominal surgery.

Aortic root reimplantation using a Valsalva graft for postoperative pseudoaneurysm after acute aortic dissection.

We report a reoperative case in which a Valsalva graft was utilized on a 64-year-old woman who had previously undergone emergency repair of a DeBakey type I acute aortic dissection. On follow-up computed tomography (CT), she was found to have pseudoaneurysms of both proximal and distal anastomoses. We performed valve-sparing aortic root replacement (VSRR) with the reimplantation technique and total arch replacement, since we felt that a graft with pseudosinuses helps to prevent torsion of the coronary arteries. The postoperative course was uneventful, and postoperative echocardiography revealed no significant aortic valve regurgitation. The pathology results raised the hypothesis that pseudoaneurysm formation might have been related to the use of gelatin-resorcinol-formaldehyde (GRF) glue at the time of the initial intervention.

Three-dimensional spectral map of atrial fibrillation by a 64-channel magnetocardiogram.

We verified the significance of 3-dimensional (3D) spectral mapping during atrial fibrillation (AFIB) using a 64-channel magnetocardiogram (MCG). The study consisted of 16 patients with valvular heart disease who had chronic AFIB. All 16 patients had surgical pulmonary vein (PV) isolation followed by valvular repair. We performed spectral mapping by fast Fourier transform analysis in nonaveraged 64-channel MCG data. The 3D spectral map was superimposed on a 3D heart polygon. At 1 year after surgical PV isolation for AFIB, followed by valve repair, 7 patients had restoration to sinus rhythm, and 9 patients remained in persistent AFIB. The preoperative mean 3D frequency of AFIB was 6.1 +/- 0.9 Hz in patients with restored sinus rhythm and 7.2 +/- 0.7 Hz in patients with sustained AFIB after PV isolation (P = .02). In addition, the preoperative 3D spectrum was distributed on the right side of the heart in patients with persistent AFIB. In conclusion, 3D spectral mapping using 64-channel MCG may represent a meaningful noninvasive strategy for patients with AFIB who receive an interventional procedure.

Ethnic differences in the VKORC1 gene polymorphism and an association with warfarin dosage requirements in cardiovascular surgery patients.

OBJECTIVES: Vitamin K epoxide reductase (VKORC1) is the drug target for inhibition by coumarin-based anticoagulant drugs such as warfarin. Warfarin therapy has been reported as a leading cause of drug-related hospitalization and there is therefore an urgent need to develop tests for better warfarin prescription. We report here the distribution of the intron 1 -136 T>C (1173 T>C intron) polymorphism of VKORC1, previously reported to be associated with warfarin maintenance dose in Caucasians and Japanese, in several ethnic populations from Japan and Israel, and describe its significance for warfarin dosage in Japanese cardiovascular surgery patients. METHODS: Subjects consisted of 132 Japanese individuals and 341 Israeli individuals from four Jewish ethnic groups (86 Ashkenazi Jews, 95 Yemenite Jews, 73 Moroccan Jews and 87 Libyan Jews). In addition, 31 Japanese patients receiving warfarin therapy after cardiovascular surgery, maintained with a target International Normalized Ratio, were studied. The genotyping for the 1173 T>C intron polymorphism of VKORC1 was determined using rapid real-time PCR. RESULTS: The allele frequency of the combined VKORC1 1173 CT and CC genotypes varied among the four Israeli ethnic groups and was, on average, much higher in the Israeli (0.728) than in the Japanese population (0.152). For the Japanese cardiovascular surgery patients, the maintenance dose of warfarin was significantly larger in the combined VKORC1 1173 TC and CC genotype group than in the 1173 TT genotype group (3.6 +/- 0.5 mg vs 2.8 +/- 0.7 mg, respectively; p = 0.02). CONCLUSION: The frequencies of the intron 1 VKORC1 1173 T>C SNP show significant differences between ethnic groups and are associated with warfarin dose requirements for achieving a recommended International Normalized Ratio range in Japanese cardiovascular surgery patients. This study supports the example of warfarin as an appropriate model for applying personalized medicine for anticoagulant drugs, and highlights the importance of ethnicity in pharmacogenetics.

Three-dimensional recovery time dispersion map by 64-channel magnetocardiography may demonstrate the location of a myocardial injury and heterogeneity of repolarization.

BACKGROUND: QT dispersion reveals heterogeneities in the repolarization time in the three-dimensional (3D) structure of the ventricular myocardium. In this study, we report on a 3D function map of recovery time (RT) dispersions as measured by 64-channel magnetocardiography (MCG). METHODS: MCG were simultaneously recorded in 29 controls and 21 patients with previous myocardial infarction (MI). The 3D current density was calculated from 64-channel MCG data in the Bz component using a space filter. The heart outline, reconstructed from the integrated the current density, revealed both the atrium and ventricle. The RT for the intervals between QRS onset and the time of the maximum dT/dt of T wave, and the peak to the end of the T wave (T(peak)-negative dT/dt) were automatically measured by means of a computer from 3D MCG data. The corrected RT (RTc) and corrected T(peak)-negative dT/dt were then calculated using Bazett's formula. The 3D RTc and the corrected T(peak)-negative dT/dt dispersion map were superimposed on the heart outline generated by MCG. RESULTS: The RTc was significantly longer for the MI group than in the control group (67+/-25 ms1/2 vs. 16+/-6 ms1/2) (p<0.0001). The corrected T(peak)-negative dT/dt dispersions in each patient was also significantly longer for the MI group than in the control group (35+/-27 ms1/2 vs. 10+/-5 ms1/2) (p<0.0001). Furthermore, the 3D RTc and T(peak)-negative dT/dt dispersion maps corresponded with the space location of MI, as defined by Tc-99m tetrofosmin myocardial imaging CONCLUSIONS: 3D RTc and T(peak)-negative dT/dt dispersion maps in the ST segment, obtained by 64-channel MCG may be used demonstrate the location of a myocardial injury and heterogeneities of repolarization.