[Negative pressure wound therapy was useful in treating empyema with bronchopleural fistula].

We report a case for whom negative pressure wound therapy (NPWT) was applied for empyema with bronchopleural fistula. The patient was a 64-year-old man with a history of gastric resection and diabetes visited our hospital with chief complaints of fever and respiratory failure. In spite of conservative treatment after being diagnosed as empyema, bronchopleural fistula developed. In order to manage the pyothorax, the bronchopleural fistula was closed with endobronchial Watanabe spigot, and fenestration was subsequently performed, however the infection control and obliteration of the empyema cavity could not be achieved. NPWT with continuous irrigation was therefore chosen, and the methicillin-resistant Staphylococcus aureus (MRSA) disappeared and a marked obliteration of the empyema cavity was observed in 3 weeks after initiation of NPWT. Although the patient died of another illness, NPWT with continuous irrigation was useful in treating empyema with bronchopleural fistula.

Acquired left ventricular-right atrial communication and severe aortic valve regurgitation caused by infective endocarditis.

We report here on a surgical case of acquired left ventricular right atrial communication (LV-RA communication) and aortic regurgitation (AR) caused by infective endocarditis (IE). We successfully treated the patient with composite patches made from polytetrafluoroethylene (PTFE) and autologous pericardium. In general, LV-RA communication is a rare congenital cardiac anomaly (Gerbode-type shunt). However, acquired LV-RA communications secondary to IE are occasionally reported.When repairing an acquired condition due to IE, particular care should be taken to avoid recurrence, persistent infection and iatrogenic atrioventricular block.

[Aortic root replacement using cryopreserved allograft for an infected aorta patient associated with mediastinitis].

We herein report a case of aortic root replacement using cryopreserved allograft. A 52-year-old man received aortic valve replacement using a mechanical prosthesis for aortic stenosis. He was complicated by postoperative methicillin-resistant staphylococcus aureus mediastinitis involving the ascending aorta. Surgical therapy including debridement, omental transposition, patch closure using pericardium had not achieved satisfied result. Aortic root replacement using cryopreserved allograft was mandatory for refractory aortic infection. He had an uneventful postoperative course. The cryopreserved allograft was effective for a patient with refractory aortic root infection due to postoperative mediastinitis.

Superior vena caval placement of a temporary filter: a case report.

Placement of permanent filters in the superior vena cava (SVC) for preventing pulmonary embolism (PE) arising from thrombi superior to the right atrium has rarely been performed. The authors report the first case of temporary filter insertion in the SVC because of upper extremity thrombosis accompanied with PE. After thrombectomy, the temporary filter was successfully removed. It is recommended to use a temporary filter, especially in young patients with upper extremity thrombosis requiring temporary prophylaxis against PE.

Clinical experience with temporary vena cava filters.

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

Double left renal vein associated with abdominal aortic aneurysm.

Double left renal vein is a rare venous anomaly. We operated on 72-year-old man of abdominal aortic aneurysm (AAA) with double left renal vein. Massive hemorrhage was encountered during encircling the tape around the abdominal aorta. One vein passing posterior to the aorta was injured. Further dissection revealed the presence of double left renal vein forming a ring around the aorta. The patient underwent an abdominal aortic replacement following prompt repair of the injured vein. He had an uneventful postoperative course without renal complication. We missed that preoperative computed tomographic (CT) scan had demonstrated double left renal vein. Preoperative contrast-enhanced CT scan is useful and essential not only for evaluation of AAA, but also for establishing the presence of venous anomalies. Venous anomalies should be taken into consideration on the AAA operation.

[Experience of four cases of postoperative pulmonary embolism requiring surgical treatment].

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.

Penetrating atherosclerotic ulcer.

The pathogenesis of penetrating atherosclerotic ulcer (PAU) in aortic disease remains controversial. Between January 1995 and April 1999, five patients underwent treatment for a PAU in our hospital. All were men, ranging in age from 46 to 74 years, with a mean age of 66.2 years. The PAU was located on the thoracic descending aorta in three patients and on the abdominal aorta in two. Preoperative diagnosis was established by contrast-enhanced computed tomographic scan and aortogram. Surgery was performed in four patients, as graft replacement in three, and patch plasty in one. The remaining patient is being carefully observed on antihypertensive therapy. No connective tissue disorder, trauma, dissection, or infection was seen in any of the patients who underwent surgery, all of whom had uneventful postoperative courses with no perioperative complications or enlargement of the aorta. We conclude that surgical treatment should be performed for patients with PAU to prevent an aortic catastrophe caused by rapid development of the lesion. This report might provide further evidence of the importance of PAU.

Thoracic and thoracoabdominal aneurysm repair under deep hypothermia using subclavian arterial perfusion.

BACKGROUND: Hypothermic circulatory arrest is a valuable adjunct for thoracic and thoracoabdominal aortic aneurysm repair. Retrograde aortic perfusion through the femoral artery, however, carries a risk of cerebral embolism or malperfusion. To avoid these complications we adopted antegrade aortic perfusion through a prosthetic graft attached to the left subclavian artery through a left thoracotomy. METHODS: Ten patients had repair of descending thoracic and thoracoabdominal aortic aneurysm under deep hypothermia with antegrade aortic perfusion through the left subclavian artery. Hypothermic circulatory arrest was used because proximal aortic control was hazardous due to rupture or intraluminal disease, or for spinal cord protection. RESULTS: There was no brain injury and one hospital death. The cause of death was massive bleeding from the gastrointestinal tract not related to deep hypothermia or the perfusion method. All 9 survivors were alive and well after a mean follow-up period of 9 months. CONCLUSIONS: Using the left subclavian artery as a site of aortic perfusion can avoid retrograde aortic perfusion, hence reducing the potential for brain injury due to embolic stroke or malperfusion through a dissected thoracoabdominal aorta.

Organ malperfusion in acute aortic dissection.

OBJECTIVE: Organ malperfusion in aortic dissection can precipitate a serious condition. The strategy of treatment for it has been controversial. We have focused on the strategy and outcome of acute aortic dissection with organ malperfusion. SUBJECTS AND METHODS: Between January 1995 and December 1998, 134 acute aortic dissection patients were admitted. There were 73 males (65.4 +/- 8.0 years old) and 61 females (66.7 +/- 7.4 years old). There were 83 patients of Stanford type A, and 51 patients of type B. Of them, 24 patients (17.9%) were complicated by organ malperfusion. The brain was affected in 4, the heart in 5, the spinal cord in 2, the liver in 1, the intestine in 1, the kidney in 4, and the lower extremities in 10 patients. Our management strategy for a patient with malperfusion in acute aortic dissection was that the antecedent operation was initially mandatory, and central grafting was secondarily considered. RESULTS: Refusal of operation or lethal conditions excluded 8 of the 24 patients from operation. An antecedent operation was mandatory in eight of the remaining 16 patients. The overall mortality was 33.3% (8/24 patients), and operative mortality was 31.3% (5/16 patients) in the patients with malperfusion. The overall mortality was 11.8% (13/110 patients), and the operative mortality was 11.1% (9/81 patients) in the patients without malperfusion. CONCLUSION: Organ malperfusion is a major component in the management and treatment of acute aortic dissection. Only an appropriate strategy and therapy could result in a satisfactory outcome.

The influence of human T lymphotropic virus type I infection on the outcome of cardiovascular surgery.

OBJECTIVE: Human T lymphotropic virus type I infects CD4(+) T cells and affects cell-mediated immunity. Cardiopulmonary bypass transiently alters lymphocyte subsets, resulting in a reduction in CD4(+) T cells and an increase in CD8(+) T cells. We proposed that cardiovascular operations and human T lymphotropic virus type I infection may act synergistically, resulting in serious damage to cell-mediated immunity. METHODS: A total of 517 consecutive patients who were preoperatively screened for anti-human T lymphotropic virus type I antibody and underwent cardiovascular operations with cardiopulmonary bypass were enrolled in this study. Of the 517 patients, 82 (16%) had positive test results for anti-human T lymphotropic virus type I antibody. The surgical outcome of patients with positive and negative results for anti-human T lymphotropic virus type I antibody was analyzed retrospectively. RESULTS: There was no difference between the 2 groups with respect to early mortality. Distribution of survival curve was also not significantly different (P =.5; mean follow-up duration, 2.4 +/- 1.8 years [range, 0-9.4 years] and 3.2 +/- 2.8 years [range, 0-9.8 years]) in the groups with positive and negative antibody results, respectively). In particular, long-term follow-up did not reveal adult T-cell leukemia or human T lymphotropic virus type I-associated myelopathy, and occurrence of neoplasm did not differ between groups. Early infectious complication was, however, significantly higher in the group with positive antibody results than in the group with negative results (P =.02). Logistic regression analysis revealed human T lymphotropic virus type I infection as a significant risk for this complication (P =.04; odds ratio, 2.5; 95% confidence interval, 1. 0-5.8). CONCLUSION: A combination of human T lymphotropic virus type I infection and cardiovascular operation is believed to increase the potential risk of infectious complications shortly after the operation. However, this synergistic effect seems to be transient and has little influence on long-term prognosis.

Preoperative autologous donation of blood for a simple cardiac anomaly: analysis of children weighing under twenty kilograms.

OBJECTIVE: Preoperative autologous donation of blood has been expanded to cardiac operations in children. However, because of problems such as lack of cooperation and hemodilution during cardiopulmonary bypass, its efficacy in small children is unclear. This study clarifies the clinical significance of preoperative autologous donation of blood in small children. METHODS: Thirty-seven patients weighing under 20 kg (age range, 3-9 years; weight range, 13-20 kg) underwent preoperative autologous donation and cardiac operations to treat a simple anomaly. Twenty-five age- and weight-matched patients who were not cooperative or refused preoperative autologous donation served as control subjects. Autologous blood was collected by the simple or leapfrog method and stored as blood components. Each collecting volume was 5 to 10 mL/kg. RESULTS: The donation was performed 6+/-2 times during 50+/-16 days, and the whole storage volume was 48+/-17 mL/kg. There was no serious complication. The minimum hematocrit level negatively correlated with the priming volume of cardiopulmonary bypass (preoperative donation patients: P<.01, r(2) = 0.4; control subjects: P =.5, r (2) = 0.03). Blood loss did not significantly differ between preoperative donation patients and control subjects, and the transfused blood volumes were 43+/-13 mL/kg and 29+/-22 mL/kg, respectively. All of the autologous blood products but fresh frozen plasma were reinfused. Use of homologous blood was significantly less in preoperative donation patients than in control subjects (0% vs 80%, P <.01). In preoperative donation patients postoperative recovery in hemoglobin level was significantly better, which is concurrent with a higher reticulocyte level. CONCLUSION: Preoperative autologous donation can be performed safely with clinical efficacy, even in children under 20 kg. This can be improved further through coupling with another procedure.

[Perioperative risk factors in valve surgery concomitant with coronary artery bypass grafting].

Between January 1990 and December 1999, 20 patients underwent the valve surgery concomitant with coronary artery bypass grafting. There were 16 males and 4 females, their mean age was 66.5 years. Of the 20 patients, aortic stenosis was noted in 7, aortic regurgitation in 3, mitral stenosis in one, and mitral regurgitation in 9 patients. The cause of mitral regurgitation was considered to be an ischemic change in six patients, including ruptured papillary muscle due to myocardial infarction in two patients. On the contrary, LMT lesion was recognized in 5, LAD lesion in 17, LCX in 16, and RCA in 12 patients. Seven patients had preoperative myocardial infarction, three patients were required preoperative IABP support. AVR was performed in 10, MVR in 5, and MAP in 5 patients. The number of bypass was 1.9 +/- 0.85. Four patients died of LOS and MOF. The remaining 16 patients have been doing well. The significant difference between the survived and the not survived patients was recognized in the factor of emergency, preoperative IABP, papillary muscle rupture due to myocardial infarction, history of PTCA, LAD lesion, and the time of CPB. The factors regarding coronary artery had the influence on the outcome of a patients of valve surgery concomitant with CABG. Therefore, an appropriate myocardial protection and perioperative management for ischemia were mandatory.

Involvement of the right atrium by malignant lymphoma as a cause of right cardiac failure: report of a case.

We describe herein a rare case of malignant lymphoma occupying almost the entire space of the right atrial cavity and causing low cardiac output syndrome. A life-saving emergency operation was carried out after the establishment of a temporary bypass between the axillary and femoral veins to prevent exacerbation of the patient's condition during the induction of anesthesia. Cardiopulmonary bypass was commenced and the right atrium was opened. A large tumor in the right atrium could not be completely removed due to invasion of the atrial wall. A bypass from the left innominate vein to the pulmonary arterial trunk was constructed with a prosthetic graft to convert the blood flow directly from the systemic vein to the pulmonary artery. Postoperative radiation treatment was given, which resulted in reducing the size of the tumor considerably, and the patient is doing well 1 year after his operation.

Watershed infarction after combined coronary and axillobifemoral bypass surgery.

Watershed infarction sometimes causes a neurological disorder due to hypoperfusion of the brain during cardiac surgery. Here we report a case in which watershed infarction developed after combined coronary artery bypass and axillobifemoral bypass surgery.

Papillary fibroelastoma on the mitral valve.

A 78-year-old woman was admitted with transient unknown fever and old cerebral infarction. An echocardiogram demonstrated mild mitral valve regurgitation and high echogenic mass on the mitral posterior leaflet. Surgery was performed with the diagnosis of a healed infective endocarditis. A sea anemone-like appearance tumor, 8 mm in diameter, was located on the mitral posterior leaflet. Annuloplasty was performed following removal of the tumor. A pathological examination confirmed the lesion was a papillary fibroelastoma. No evidence of infective endocarditis was seen. The cause of the fever remained unknown. The tumor was very fragile. Surgical removal was mandatory for preventing embolism despite the advanced age.

Operation for adult patent ductus arteriosus using cardiopulmonary bypass.

BACKGROUND: Surgical repair of adult patent ductus arteriosus is more hazardous than when performed on young patients. METHODS: Nine adult patent ductus arteriosus patients underwent surgical repair between January 1986 and December 1998. There were 3 male and 6 female patients (mean age 55.0 years). The ratio of pulmonary blood flow to systemic flow was 2.40 +/- 0.95, and pulmonary arterial pressure was 56.0 +/- 26.4 mm Hg. The operation was performed using transpulmonary approach under total cardiopulmonary bypass. Balloon occlusion method was also utilized. RESULTS: Direct closure was made in 5 and patch closure in 4 patients. Cardiopulmonary bypass and balloon occlusion were safely established. Cardioplegic arrest was not required in the 2 most recent patients. No operative death has occurred. Pulmonary arterial systolic pressure decreased to 35.3 +/- 6.6 mm Hg at 6 months after operation. The mean follow-up period for all patients is 55 months. To date, neither recannalization of the ductus nor pseudoaneurysm has been recognized. CONCLUSIONS: Cardiopulmonary bypass with balloon occlusion provides a safe operation for adult patients with complicated patent ductus arteriosus.

Distal arch aneurysm repair using stent-grafting and ascending aorto-left axillary bypass.

BACKGROUND: Transcatheter application of a stent-graft to the angulated aortic segments with critical side branches poses some problems. We report our technique of distal arch aneurysm repairs using stent-grafts inserted through the aortic arch and ascending aortoaxillary bypass. PATIENTS AND RESULTS: Three patients underwent successful distal arch aneurysm repair using a homemade semiflexible stent-graft placed under hypothermic circulatory arrest. The left subclavian artery was reconstructed by an extraanatomic bypass grafting between the ascending aorta and left axillary artery. Postoperative imaging demonstrated reduction of aneurysm size and no endoleaks from an intercostal artery. CONCLUSIONS: Our technique seems to be useful for repair of distal arch aneurysms and is a less invasive procedure.