[Infective endocarditis with acute embolism to the lower extremity artery caused by a vegetation: report of a case].

Successful surgical treatment of a case of infective endocarditis with embolism to a lower extremity artery is reported. A 71-year-old man was referred to our hospital for the treatment of infective endocarditis. Echocardiography showed a vegetation on the non-coronary cusp of the aortic valve measuring 19 mm in diameter. We planned surgical treatment, including aortic valve replacement, however, embolism of a lower extremity artery by the vegetation occurred during the waiting period for the operation. We removed the offending vegetation from the popliteal artery and replaced the peccant aortic valve with a prosthetic valve in separate operations. The postoperative course was uneventful and the patient was transferred to another hospital on the 33rd day after the valve replacement surgery.

[A case of traumatic aneurysm of innominate artery with occlusion of right subclavian artery].

A 42-year-old woman with history of chest blunt trauma from an automobile accident 250 days earlier had suffered easy fatigability of the right upper extremity. She had difference of blood pressure between upper extremities, 94/60 mmHg in the right and 126/70 mmHg in the left. Chest CT showed dilation of the innominate artery which compressed the trachea. Aortography showed an aneurysm of the innominate artery and occlusion of the right subclavian artery at its origin. The aneurysm of the innominate artery was resected and replaced with a 6 mm Dacron graft with aid of the external shunt. The right subclavian artery was also reconstructed with same graft. The aneurysm of the innominate artery should be suspected as a rare complication in blunt trauma of the chest.

Pericardial drainage prior to operation contributes to surgical repair of traumatic cardiac injury.

We report on two cases of successful surgical repair of cardiac injury: one involving a left ventricular stab injury and the other a blunt rupture of the right atrium. Each patient underwent emergency surgical repair, the former via left anterolateral thoracotomy and the latter via median sternotomy, following pericardial drainage tube insertion from the subxiphoid area. The operative approach was chosen according to the color of drained blood, i.e., arterial bleeding indicated left anterolateral thoracotomy, while venous bleeding indicated median sternotomy. We conclude that pericardial drainage via the subxiphoid approach prior to induction of anesthesia is an easy and useful technique to perform, not only to release cardiac tamponade but to determine the operative approach in patients suffering from cardiac tamponade following cardiac injury.

[Coronary artery bypass grafting in two patients with single coronary artery].

We experienced two patients with single coronary artery who underwent CABG using arterial grafts successfully. In two patients coronary angiography demonstrated a single coronary artery which was originated in left coronary sinus and was bifurcated to LAD and LCx, and then RCA branched off proximal LAD, passing in front of the right ventricular out flow tract (Sharbaugh Type L-IIa). To the first patient, a 52-year-old man who had angina on exertion due to long stenosis of RCA, CABG to RCA using RITA was carried out. To the second patient, a 57-year-old man who had inferior myocardial infarction due to 90% stenosis of proximal LAD, CABG to RCA using RITA and LAD using LITA was carried out. Single coronary artery without additional congenital cardiac anomalies may lead to myocardial ischemia, necessitating CABG as coronary reconstructions.

[A case of spontaneous hemopneumothorax occurred after thoracic drainage].

A 21-year-old man; complaining of left chest pain and dyspnea, was admitted to our hospital with a diagnosis of spontaneous pneumothorax. Though chest X-ray on admission did not show hemothorax, chest drainage revealed intrapleural bleeding. As chest X-ray on the following day showed evident fluid level, emergency operation was carried out with a diagnosis of spontaneous hemopneumothorax. Bleeding point was a ruptured vessel between parietal pleura and bulla in apex of lung. The bulla was resected following hemostasis. After improvement of complicating postoperative re-expansive pulmonary edema, the patient was discharged on the 18th postoperative day. On treatment of spontaneous hemopneumothorax, existence of such a case as ours should be taken into account.

[A case of a chronic traumatic thoracic aneurysm with compression of left main bronchus at the isthmus].

We report a case of traumatic thoracic aortic aneurysm found by occurrence of pulmonary atelectasis in the chronic phase. The patient, an 18-year-old female, was hospitalized with multiple trauma caused by a traffic accident. At the time of hospitalization, no thoracic trauma was found but a fracture of the pelvis and one leg was recognized. 45 days after the initial trauma, a pulmonary atelectasis on the left lung was found on a chest X-ray film. By chest CT and angiography, the pulmonary atelectasis was proved to be caused by compression of the left main bronchus by a traumatic aneurysm of the thoracic aorta. 55 days after the initial trauma, resection of the aneurysm and graft replacement was performed. Postoperative course was satisfactory. In conclusion, possibility of an injury to the thoracic aorta should be considered on the treatment for the patient with multiple trauma in the chronic phase as well as in the acute phase.

[Removal of the left atrial myxoma combined with coronary artery bypass grafting in an elderly patient].

The case of simultaneous coronary artery bypass grafting with resection of the leat atrial myxoma is rarely reported. We surgically treated a 81-year-old woman who had been diagnosed as left atrial myxoma and unstable angina. At surgery we performed coronary artery bypass grafting prior to resection left atrial myxoma, because we thought it is the most important to protect myocardium by antegrade cardioplegia in the consequence of CABG. Postoperative course was excellent and uneventful. The patient is doing well now.

[A case report of aortic valve replacement and ascending + hemi aortic arch replacement for congenital bicuspid aortic stenosis with poststenotic dilatation of ascending aorta].

The patient of 21-year-old female, who had undergone VSD closures at the age 5 and had been pointed out to have aortic valve stenosis at that time, was admitted to our hospital with complaints of palpitation and easy fatigability. Pressure gradient of 140 mmHg between left ventricle and ascending aorta, and poststenotic dilatation of max 55 mm in diameter from ascending aorta to hemi aortic arch was recognized by cardiac catheterization and aortogram. For fear of aortic dissection in late phase caused by dilatation of ascending aorta left over, graft replacement from ascending aorta to hemi aortic arch was carried out simultaneously adding to aortic valve replacement (AVR). We are of the opinion that not only AVR but also simultaneous graft replacement should be performed actively on the case with dilatation of ascending aorta of over 55 mm in diameter in order to prevent aortic dissection.

Anatomy of inferior pulmonary vein should be clarified in lower lobectomy.

We successfully performed surgery for carcinoma of the lung on 2 patients with the anatomic variation of the middle lobe vein draining to the right inferior pulmonary vein. This variation is surgically important because division of the right inferior pulmonary vein may result in blockage of middle lobe vein drainage in right lower lobectomy. Surgeons must always pay attention to this variation when performing the right lower lobectomy.

[A case report of a pseudoaneurysm of the thoracic aorta (thrombotic closure type) showing like a mediastinal tumor--value of endoscopic ultrasonography in differential diagnosis].

A 65-year-old male patient was refered to our hospital for abnormal mediastinal shadow. CT and MRI study showed an inhomogeneous mediastinal tumor simulating neoplasm neighboring the aortic arch. Thoracic aortogram did not revealed the existence of thoracic aortic aneurysm. But the endoscopic ultrasonography (EUS) showed a pseudoaneurysm with a 2 cm entry site. The diagnosis of pseudoaneurysm was therefore proved, so the patient underwent the operation safely with preparation for extracorporeal circulation. Some patients with chronic thoracic pseudoaneurysm has no history of chest trauma and other causes. It is valuable to perform EUS for the differential diagnosis of abnormal mediastinal shadow which shows like a mediastinal tumor.

[Effects of blood-diltiazem-nitroglycerin-cardioplegia in coronary artery bypass grafting].

Forty-seven patients who underwent coronary artery bypass grafting using blood cardioplegia (BCP) were studied clinically. They were divided into 3 groups based on concentration of diltiazem (DTZ) and nitroglycerin (NTG). Group I (n = 12); DTZ 5 mg plus NTG 5 mg in BCP 1,000 ml, Group II (n = 10); NTG 25 mg in BCP 1,000 ml, Group III (n = 25); DTZ 5 mg plus NTG 25 mg in BCP 1,000 ml. From the standpoint of serum enzyme analysis, there was no significant difference between 3 groups, however, the incidence of perioperative myocardial infarction (PMI) and perioperative coronary spasm (PCS) were significantly higher in Group I than that in other groups. The present data suggests that intramyocardial concentration of NTG in Group II and III were 5 times higher than Group I. Increased dose of NTG in BCP would be benefit for myocardial protection in CABG.

[Surgical repair of descending aortic aneurysms--experience in 100 patients under partial cardiopulmonary bypass].

Between 1975 and 1986, 100 consecutive patients with aneurysms of the descending thoracic (84 cases) or the thoracoabdominal aorta (16 cases) underwent surgical repair. Intraluminal graft inclusion procedure was employed in principle under routine circulatory support with partial cardiopulmonary bypass. In this study, overall surgical results were reviewed, and multiple factors discriminately contributing to early results were assessed using multivariate analysis (quantification theory type II) to determine if this therapeutic modality is pertinent. Fifty-five patients had non-dissecting, 42 had dissecting aneurysms and 3 had pseudoaneurysms. Seventeen patients were treated in the emergency setting. Perioperative or early deaths occurred in 14 patients. Mortality increased with advanced age (greater than 70 years) and with atherosclerotic aneurysms, especially when they involved the entire thoracic or thoracoabdominal aorta. Operative mortality during the last 5 years of the study was 9.3%: significantly lower than the figure in the first 5 years of 28% (p = 0.0198). The incidence of renal dysfunction (7.4%) or paraplegia (2.1%) was not related to aortic cross-clamp time, and both were markedly decreased to 3.8% and 0.0%, respectively, when the cases of thoracoabdominal aneurysms were excluded. There were 8 cases of exploration for postoperative hemorrhage and 6 cases of pulmonary insufficiency requiring more than 3 days of mechanical ventilation. Prolonged bypass time was a discriminative risk factor for these two complications. Cerebral vascular accidents developed in 5 patients, three of them terminated in death. In spite of partial bypass, the factors of advanced age, atherosclerosis, and cross-clamp on the aortic arch were defined responsible for brain stroke.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case report of surgical treatment of dissecting aneurysm of the thoracic aorta (DeBakey IIIb) with chronic renal failure].

The patient has been receiving hemodialysis (H.D.) for chronic renal failure due to polycystic kidney since last February. He suddenly had back pain and short of breath February 8, 1988. He was pointed out to have hypertension and cardiomegaly on chest roentgenogram. He was transferred to our hospital, and suspected dissecting aneurysm. Magnetic resonance imaging was useful for the diagnosis of the dissecting aneurysm and may have a potential advantage in following up the residual false lumen. The patient underwent graft inclusion technique for dissecting aneurysm of the thoracic aorta of type IIIb with an aid of partial femoro-femoral bypass. The water and electrolytes balances were controlled by GI therapy and hemoconcentrator during operation. Since serum potassium level was gradually increasing up to 7.8 mEq/l inducing arrhythmias with coronary arterial spasm postoperatively, H.D. was instituted. The induction of H.D. was easily performed with satisfactory results. Heparin was not used while blood coagulation profiles tended to be low in early postoperative period. He returned to his work this August.

[Clinical study on surgical treatment of aortic arch aneurysm using selective cerebral perfusion or hypothermic circulatory arrest].

To improve the surgical results of aneurysms of the transverse aortic arch, it is essential to select the optimal support technique to protect the cerebral ischemia during the aortic arch occlusion. In the four year period between 1983 and 1987, 21 consecutive patients had surgical correction of aneurysms of the transverse aortic arch at our institution. The causes of aneurysms were dissection (type A) in 16 patients and arteriosclerosis in 5 patients. Seven patients had emergency operation for frank or impending rupture. Two method for cerebral protection were employed during the period of arch exclusion. In Group I, 11 patients underwent selective cerebral perfusion both to innominate and left common carotid arteries via one roller pump at a rate of 600 ml/min (25 degrees C). The average cerebral perfusion time was 70.4 +/- 20.5 minutes. In Group II, 10 patients underwent deep hypothermia (15 degrees C to 20 degrees C) and total circulatory arrest to allow repair of the transverse aortic arch. The concomitant AVR was performed in two patients and CABG in one patient. The average cerebral arrest time was 35.2 +/- 3.4 minutes. Two out of 10 patients had additional cerebral perfusion because cerebral ischemic time exceeded over 45 minutes. There were three early deaths (14.3%) in this series. The causes of early death were bleeding in two patients and renal failure in one patient. There were no cerebral complications in both groups. The duration of extracorporeal bypass necessary for cooling and rewarming phase in Group II was longer than that in Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Traumatic occlusion of the bilateral vertebral arteries associated with fracture of the cervical spine--a case report].

A case of traumatic occlusion of the bilateral vertebral arteries associated with fracture of the cervical spine is reported. A 34-year-old man, having no previously noted medical problems, fell to the bottom of a bathtub with a depth of 80 cm, and hit the vertex fronto-parietal region of his head. He was transferred to our hospital 6 hours after his fall with a crush fracture of the cervical spine at the C6 level. On admission he was alert, but having pain in the vertex region, dysarthria, blurred vision and hemiparesis. Roentgenograms confirmed a crush fracture of the C6 vertebral body. Computed tomograms of the brain revealed a high density of basilar artery. Cervical traction with a Halo brace was then carried out. Twelve hours after the trauma, left oculomotor and right facial palsy appeared followed by bilateral oculomotor palsy and respiratory difficulty. At the 14th hour, he displayed bilateral Babinski's signs and tetraparesis. Tetraparesis became complete with right-side Horner's syndrome at 16 hours. Cerebral arteriograms performed 20 hours after the trauma showed a complete occlusion of the right vertebral artery and an incomplete occlusion of the left vertebral artery at the C6-7 intervertebral disk space. Conscious level deteriorated to a 200 level on the Japan coma scale 28 hours after the trauma and to a 300 level after 32 hours. Computed tomograms revealed a marked low density on the cerebellum and brain stem 38 hours after the accident. He expired on the 22nd day after the trauma.(ABSTRACT TRUNCATED AT 250 WORDS)