Traumatic cardiac rupture with acute ascites.

A rare accumulation of serous ascites following traumatic cardiac rupture is reported for a 21-year-old man transferred to the emergency center of our hospital from a community hospital suffering from severe shock due to a motorcycle accident. Computed tomography scan showed moderate pericardial and intrapelvic fluid accumulation strongly suggesting cardiac and visceral injuries. An emergency sternotomy disclosed a rupture of the right atrial appendage, successfully closed with primary sutures. A laparotomy was done to aspirate moderate serous fluid, which was clear and not bloody. Edema of the retroperitoneal space and hepatic congestion were noted with no accompanying organ injury. Ascites pathogenesis is unknown but appeared to be related to portal venous congestion induced by cardiac tamponade combined with massive intravenous fluid infusion done to correct the patient's deteriorating hemodynamics.

Purulent pericarditis due to group B streptococcus and mycotic aneurysm of the ascending aorta: case report.

A 61-year-old female, with a history of uterine and cervical cancer treated with radical hysterectomy and 2 years of postoperative chemotherapy, presented to the emergency department with dyspnea on exertion. Computed tomography of the chest revealed a large pericardial effusion and a sacciform aneurysm of the ascending aorta. The patient subsequently underwent emergency pericardiocentesis with drainage of approximately 330 ml of a bloody and turbid effusion. Cultures from the effusion yielded group B streptococcus. Multiple organ failure and disseminated intravascular coagulation syndrome occurred in the acute phase, but gradually improved with continuous antibiotic therapy. On the 194th hospital day, in situ reconstruction of the ascending aorta was successfully performed using a synthetic graft. Although rarely reported, both purulent bacterial pericarditis and mycotic aneurysm can be life-threatening.

Right atrial isolation for atrial fibrillation associated with atrial septal defect.

Two patients with atrial fibrillation associated with an atrial septal defect underwent simultaneous surgical correction of the atrial septal defect and right atrial isolation. The right atrium was surgically isolated while the continuity with the sinoatrial node was preserved in the remainder of the heart. After the operation, the patients maintained normal sinus rhythm for 99 and 65 months. Thus, right atrial isolation offers an alternative to the current surgical treatment for atrial fibrillation associated with an atrial septal defect.

Infective endocarditis. Considerations for the timing of surgical intervention and type of infecting microorganism.

To determine the appropriate timing for surgical intervention in infective endocarditis (IE), we evaluated 24 patients (17 males, 6 females, with one included twice) who underwent surgical intervention for IE of native valves (NVE, n = 21) and prosthetic valves (PVE, n = 3) between January 1989 and September 1994. The mean age was 41 +/- 13 years (range 6 to 64 years). The most common infective organisms were Staphylococcus (33% of NVE) and Streptococcus (19% of NVE), with five NVE patients (24%) negative for blood culture. The PVE patients showed a different pattern of infecting organisms, with Enterococcus in one and Pseudomonas in another. From the resected valve culture and pathological findings, 12 patients were in the active stage at operation. Two in-hospital deaths occurred for a mortality rate of 8.7% (2/23). Further, surgical interventions were performed earlier with Staphylococcal infections than with Streptococcal infections, because hemodynamic compromise presented more progressively in the former. Also resected valve cultures and the pathological findings showed that a persistent infectious process existed in many cases of Staphylococcal infection in spite of intensive antibiotic therapy. In conclusion, we suggest that internists make referrals for surgical intervention for patients with NVE or PVE as early as possible in the active stage of infection.

Superior-septal approach for transmitral mapping and cryoablation of ventricular tachycardia.

A superior-septal approach was used for mapping and cryoablation of the left ventricular endocardium over the mitral annulus in a patient with ventricular tachycardia associated with an inferior myocardial infarction without a ventricular aneurysm. This approach provides an excellent view of the mitral valve, and allows safe, adequate mapping and cryoablation of the left ventricular endocardium without the necessity of a ventriculotomy.

A case report of simultaneous surgery for Wolff-Parkinson-White syndrome combined with hemolytic anemia and mitral stenosis.

A 46-year-old woman with mitral stenosis, WPW syndrome, hemolytic anemia due to spherocytosis, and hypothyroidism with Hashimoto's thyroiditis, was admitted with palpitations and dyspnea due to paroxysmal atrial fibrillation with a rapid ventricular response, and was treated by electrical cardioversion. We selected surgical intervention to treat the mitral stenosis and WPW syndrome, as some tachycardia episodes due to atrial fibrillation have resulted in repeated congestive heart failure. In 1983 we simultaneously performed a division of the posteroseptal accessory pathway and a mitral valve replacement with a bioprosthetic valve under cardiopulmonary bypass, using a membrane oxygenator after splenectomy to compensate for the hemolytic anemia due to spherocytosis. Her postoperative course was favorable and she is now in good health with no episodes of tachycardia, congestive heart failure nor anemia occurring during the 10 years that have followed the operation. Simultaneous surgery for WPW syndrome combined with other cardiac abnormalities and hematologic disorders achieved acceptable results in this case.

Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease.

BACKGROUND: A computerized 32-channel mapping system has been developed to investigate the characteristics of the atrial activation sequence. The system is capable of displaying sequential atrial maps and provides a rapid and dynamic means of verifying the activation sequence of atrial fibrillation. METHODS: Using this system, we performed intraoperative atrial activation mapping in 10 patients with chronic atrial fibrillation who were undergoing isolated mitral valve operations. RESULTS: Regular and repetitive activation (cycle length ranged from 131 to 228 milliseconds) originated in the left atrium in all 10 patients. Two patterns of repetitive activation in 2 patients and three patterns in 1 patient appeared alternately during the observation period in the left atrium. In contrast to the repetitive activation in the left atrium, the activation sequence of the right atrium was extremely complex and chaotic. In 7 of the 10 patients, the same pattern of right atrial activation was never repeated during the observation period. In 2 patients, revolution of repetitive activation in the right atrium sporadically appeared, but the pattern of activation immediately deteriorated to a complex and chaotic pattern. In 1 patient, repetitive activation emerged from the low lateral portion of the right atrium. Because our mapping technique was limited by the number of available atrial electrodes, discrete reentrant circuits or ectopic foci could not be demonstrated in the present study. However, the activation sequences during chronic atrial fibrillation suggested that (1) the left atrium would act as an electrical driving chamber for atrial fibrillation in the majority of the patients and (2) atrial activation patterns are different in each case. CONCLUSIONS: Computerized intraoperative mapping should guide surgeons in determining the appropriate surgical procedure and facilitate operation for chronic atrial fibrillation associated with mitral valve disease.

[Evaluation of internal thoracic artery bypass grafting with perfusion contrast echocardiography].

Intraoperative perfusion contrast echocardiography (PCE) is a new method to evaluate regional myocardial perfusion using Albunx (air encapsulated albumin microspheres-Molecular Biosystems, Inc.) and has been employed by direct individual injection into human saphenous vein coronary bypass grafts. Because this is not an appropriate technique for assessing left internal thoracic artery (LITA) graft, we tested the hypothesis that PCE can be performed with a single aortic root injection and, thereby, provide regional perfusion data for LITA and native coronary flow. CABG (LITA to the left anterior descending artery (LAD) was performed in adult swine. PCE was performed in each of the following conditions: 1) LITA occluded, LAD 100% flow; 2) LITA 100% flow, LAD occluded; 3) LITA 50% flow, LAD occluded; and 4) LITA and LAD occluded. Time-intensity curves were constructed to assess the time to initial appearance of myocardial enhancement (TIA), peak contrast intensity (PI), and area under the enhancement curve (AUC). In 12/14 cases, (85.7%), adequate enhancement was achieved. LITA perfusion, when compared to perfusion through the native LAD, showed delayed appearance (TIA 0.4 +/- 0.1 vs 1.9 +/- 0.2 secs), reduced PI (43 +/- 3 vs 28 +/- 3 AU) and reduced AUC (247 +/- 115 +/- 19 AU) (p < 0.01) when LITA flow was reduced 50%, TIA was prolonged (1.7 +/- 0.2 vs 2.4 +/- 0.2 secs) and AUC was reduced (152 +/- 18 vs 88 +/- 20 AU) (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Perinodal cryomodification for supraventricular tachycardia].

The perinodal cryomodification procedure ablates the surrounding tissue of atrioventricular node, as a consequence, eliminates atrioventricular nodal reentrant tachycardia (AVNRT) and reduces the ventricular response during atrial fibrillation. We performed the procedure in 4 patients: 2 patients with AVNRT, 1 patient with atrioventricular reciprocating tachycardia utilizing a left side accessory pathway and atrioventricular node dual pathways, and 1 patient with tachycardic atrial fibrillation. The concomitant procedures include a closure of atrial septal defect and a mitral valve replacement. All the patients survived the procedure and cured the tachycardia. Post operative electrophysiological studies showed that the retrograde conduction over the atrioventricular node was eliminated while the antegrade conduction was preserved in the patients with atrioventricular node dual pathways. The perinodal cryomodification is a safe and effective procedure to cure the tachycardia, particularly in the patients with a structural heart disease.

Continuous and stable recording of the His bundle electrogram during open heart operations.

We describe a method for continuously recording the stabilized His bundle electrogram from the aortic root during open heart surgical procedures. This simple technique was useful in all surgical procedures for the oblation of supraventricular tachyarrhythmias in the region around the atrioventricular conduction system.

Clinical evaluation of a new type of centrifugal pump.

The major problems with existing centrifugal pumps are leakage, mechanical trauma, and thrombus formation. In consideration of these problems, a new compact centrifugal pump system was developed. The purpose of this study was to evaluate the new centrifugal pump system clinically. Ten patients underwent open heart surgery with a centrifugal pump or a roller pump. During surgery, hemodynamic and hematological data were obtained. A pulsatile assist device in the pump circuit was used in patients with severe heart disease. There was neither operative death nor hospital mortality, and there was no difference with regard to hemodynamic data between the two groups. The centrifugal pump groups, however, had significantly lower hemolysis, especially during prolonged cardiopulmonary bypass. This centrifugal pump could also create sufficient pulsatile flow with a pulsatile assist device. Postoperative macroscopic and microscopic findings demonstrated the smooth surface of the pump without thrombus formation. This centrifugal pump system might be useful for prolonged cardiopulmonary bypass.

Congenital aortic regurgitation caused by a rudimentary noncoronary cusp: report of a case.

A 14-year-old asymptomatic boy was admitted to our department for investigation of a diastolic murmur which had been discovered by his family doctor during a routine examination. Echocardiography showed aortic regurgitation with dilatation of the left ventricle. Inspection of the aortic valve at the time of operation revealed normal left and right cusps with a rudimentary noncoronary cusp. An aortic commissuro-plication was performed and a new bicuspid aortic valve successfully reconstructed. His postoperative course was uneventful and he has been well and leading an active life since his discharge from hospital.

[Myocardial protection with pulsatiled retrograde coronary sinus perfusion--using Emax for left ventricular contractility].

Recently retrograde coronary sinus perfusion technique has been frequently used in patients with severe coronary artery disease. However many untoward effects, such as tissue edema and hemorrhage, have also noticed. To evaluate the efficacy of retrograde cardioplegia, 24 mongrel pentobarbital anesthetized dogs were studied. To create hypoperfused area, distal portion of the left anterior descending coronary artery (LAD) was occluded. After cardioplegic arrest under cardiopulmonary bypass, dogs were assigned following 3 experimental groups (8 dogs each). Group I; Glucose-Insulin-Potassium (GIK) solution (K: 20 mEq/l, 20 ml/kg) was given antegradely into the aorta. Group II; GIK was given retrogradely through the coronary sinus. Group III; GIK was given retrogradely with pulsatile device (synchronized retroperfusion pump system). After 30 minutes, same amount of GIK was given again. Then LAD occlusion was released. Sixty minutes after onset of arrest, the aorta was declamped and cardiopulmonary bypass was stopped. The left ventricular contractility (Emax) measured with conductance catheter at the end of experiment was significantly (p < 0.05) better in groups II (13.1 +/- 2.6, mean +/- SD) and III (13.1 +/- 2.9) than in group I (9.6 +/- 2.7). The left ventricular wall-motion measured with ultrasound crystals in hypoperfused area compared to before cardiopulmonary bypass was also significantly better in groups II (76.2 +/- 17.2%) and III (87.9 +/- 16.9%). Regional myocardial temperature suggested that more rapid and homogeneous cooling including right ventricle was achieved in group III than in groups I and II. Retrograde perfusion is more effective method in the setting of coronary stenosis compared to ordinal antegrade technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful combined operation for mitral stenosis and atrial fibrillation.

Simultaneous surgical treatment of mitral stenosis and atrial fibrillation was performed. The patient's postoperative course was uneventful, the rhythm changed to sinus rhythm, and the patient was discharged on the 21st postoperative day in stable condition.

[Malfunction of mitral and tricuspid Ionescu-Shiley pericardial xenografts].

We report a case of the malfunction of Ionescu-Shiley pericardial xenografts (ISPX) in the mitral and tricuspid positions at 6 years after implantation. The patient underwent an emergency operation successfully despite his high age (75 years) and extremely poor preoperative condition. The valve extracted from the mitral position showed spontaneous disruption of the leaflet, while the tricuspid valve graft was entangled with the preserved native septal leaflet around the stents. This former complication is now widely recognized, but the latter one appears to be rare. Care should be taken in replacing the atrioventricular valve with a bioprosthesis when the native valve leaflets are not removed. Although the ISPX is no longer in clinical use, careful follow-up is mandatory in patients with this prosthesis especially when it was implanted in the mitral position.