[Penetrating thoracic injury].

PURPOSE: To clarify the clinical aspects of penetrating thoracic injury. PATIENTS AND METHODS: Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. RESULTS: There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. CONCLUSIONS: Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death.

[Right atrial lipoma with calcification in ascending aorta; report of a case].

A 67-year-old male was diagnosed to have a right atrial tumor by echocardiography incidentally. Computed tomography (CT) indicated a mass which showed very low radiodensity and magnetic resonance imaging (MRI) [T1-weighted] showed the high signal intensity of tumor. We could predict the mass as lipoma. Tumor removal was performed under cardio-pulmonary bypass and under ventricular fibrillation because of the calcification in ascending aorta. Microscopically the tumor was consisted of mature adipose tissue. The postoperative course was uneventful. Cardiac lipomas are rare tumors. CT and MRI are better investigations for preoperative diagnosis. After surgical excision the prognosis is excellent.

[Surgical treatment of coronary artery-pulmonary artery fistula with coronary aneurysm].

We experienced 4 cases of coronary artery-pulmonary artery fistula with coronary aneurysm, three patients had symptoms of chest pain, and 1 patient had cardiac murmur. Coronary arteriography showed that three patients had fistulas from the left coronary artery to the pulmonary artery; and that 1 patient had a fistula from both the right and left coronary arteries to the pulmonary artery. Moreover, 1 patient had 90% diameter stenosis of segment 7. The maximum diameter of the coronary aneurysm ranged from 12 to 20 mm (average: 15.3 mm). One patient underwent closure of the opening of the fistula, 2 patients underwent multiple ligatures of fistulas, and 1 patient underwent multiple ligatures of fistulas with coronary artery bypass grafting. The postoperative course of every patient was uneventful. There have been 42 reports on this abnormality in Japan. We should treat the fistula as early as possible to prevent cardiac complications such as myocardial ischemia and rupture of coronary aneurysm.

[Evaluation for factors associated to early tracheal extubation after coronary artery bypass grafting].

Recent studies suggest that early tracheal extubation after coronary artery bypass grafting (CABG) may reduce intensive care unit use and cost. During recent two years, 96 patients were underwent CABG under cardiopulmonary bypass by low-dose fentanyl and isoflurane anesthesia. We compared two groups of patients for evaluation of factors associated to early tracheal extubation. 47 cases (Group A) were extubated within six hours (average 4.4 hrs) following operation, and 26 cases (Group B) were extubated later than twelve hours (average 57.5 hrs). It is suggested that emergency cases, female, elderly patients, dysfunction of kidney and long operation time associated to late extubation. But early extubation after CABG does not increase perioperative morbidity except for the cases that fell in low cardiac output syndrome or postoperative respiratory complications.

[New method for closure of median sternotomy: usefulness of barbed staple].

In this report, 15 cases using straight staple (group A) and 35 cases using barbed staple (group B) were compared for the purpose of investigating efficacy for median sternal closure. The staples were placed by a Stapilizer powered metaphyseal staple system following partial transsternal fixation with two wires. As a means of assessing the status of back out, which is a major cause of poor fixation, the back out rate (BOR) was measured on lateral sternal radiographies. The average BOR was found to be 33.8% in group A and 21.2% in group B (p < 0.001). Barbed staples seemed to be more useful for sternal fixation than straight staples. This method of applying barbed staples had the advantages of speed, ease of insertion and noninvasion of the retrosternal region. It should be recommended in cases with severe adhesion of the retrosternal region after coronary operation.

Antiplatelet therapy following cardiac valve replacement-a comparative study of aspirin and ticlopidine.

The antiplatelet agents, aspirin and ticlopidine, are widely used to prevent thromboembolism following cardiac valve replacement. To compare the clinical effects of each platelet inhibitor, a daily dose of ticlopidine 300 mg was given to 50 patients who underwent aortic valve or mitral valve replacement with an average age of 56.9 years over a mean 52.6 months after surgery. 50 more patients with an average age of 50.2 years were given a daily dose of aspirin 81 mg over a mean 51.3 months after surgery. Warfarin was given to maintain thrombotest values at 10 to 25% (PT-INR at 1.6-3.0). The incidence of thromboembolism was low in both groups; 1.0/100 patient years in the ticlopidine group and 1.9 in the aspirin group. Hemorrhagic complications, hematuria and ecchymosis, showed an incidence of 2.9 in the ticlopidine group and 2.3 in the aspirin group. Slight increases in GOT and GTP were observed in 4 and 18% of cases and elevated total cholesterol and neutral fat in 2 and 18% of cases. No adverse reactions were reported. With the exception of a significant decrease in ADP-induced platelet aggregation in patients who took ticlopidine, there were no significant differences observed between the two groups.

Six year experience with wrinkled ePTFE vascular prostheses for arteriosclerosis obliterans.

From November 1986 to January 1993, 97 wrinkled ePTFE prosthetic vascular grafts were implanted in 90 peripheral arterial reconstructions for 87 patients with arteriosclerosis obliterans (ASO) (79 men and 8 women). Grafts used in this series were 54 Vitagraft and 33 Technograft. Initial results for a period of as long as 6 years are summarized here. Forty-four (45.3%) grafts were implanted anatomically, and the remaining were extra-anatomically routed. The mean age of patients in the anatomic bypass group was 64.7 years, and that of patients in the other group was 71.4 years. Twenty-three (43.3%) grafts in the extra-anatomic group were anastomosed sequentially. Mean follow-up periods for each group were 32.4 months and 30.9 months, respectively. None of nine late deaths during the follow-up period was graft related. There was one primary obstruction in the anatomic group; in the extra-anatomic groups, primary graft occlusion occurred in four grafts. In addition, one perigraft seroma and one pseudoaneurysm requiring surgical repair were seen. Cumulative event free ratio for this group was 80.8% at 72 months. These results reveal that the wrinkled ePTFE graft is clinically applicable to arterial reconstruction for ASO with satisfactory long-term patency, even in extra anatomic sequential bypasses.

[A case of ruptured distal arch aneurysm associated with postoperative unilateral respiratory disorders].

This paper describes a patient with ruptured distal arch aneurysm associated with postoperative unilateral respiratory disorders whose life was able to be saved by surgery. The patient was a 68-year old male who underwent emergency surgery due to sealed rupture of distal arch aneurysm while preparing for selective surgery. Artificial graft replacement of the distal arch was carried out under centrifugal pump bypass. Respiration was controlled using differential lung ventilation (DLV) techniques. This was done because weaning from the respirator was difficult due to decreases in lung-thorax compliance on the opened chest side after surgery. Weaning from the respirator was achieved on the 10th day of illness after surgery. Postoperative prognosis of ruptured thoracic aneurysm is extremely poor, with high mortality being attributable to the fact that most patients are elderly and the incidence of respiratory and cardiovascular complications is very high. In addition, problems are often encountered in postoperative respiration management in patients with thoracic aneurysm who need open chest surgery. DLV seems to be a useful support in such patients who have underlying respiratory disorders.

[Clinical study of centrifugal pump bypass as an auxiliary technique for surgical treatment of descending thoracic aorta].

Left heart bypass or arterial bypass using a centrifugal pump (Bio-pump bypass) with a H-PSD shunt tube was performed as an auxiliary technique for the treatment of descending thoracic aorta in 13 cases. Hemodynamic differences during aortic clamp were compared between cases using Bio-pump bypass and 4 cases of axillo-femoral temporary bypass which were carried out in the first term. Furthermore, in Bio-pump bypass cases, the bypass route was investigated from the point of view of operative complications in relation to bypass technique. Peripheral blood pressure and urinary output during aortic clamp were significantly increased in the Bio-pump bypass group. Those results indicated that the Bio-pump bypass was useful as an auxiliary technique especially for high risk patients with low renal function. In particular, left heart bypass was a beneficial technique which was not affected by modality or region of disorder in the descending thoracic aorta. However, this technique should be selected carefully for patients with cardiac disease, for instance severe left ventricular hypertrophy, because two cases of operative complications consisting of pericardial effusion related to the bypass technique were experienced in this study.

[Surgery of atrial septal defect in patients aged over 40 years: comparative study of direct suture and patch closure].

Thirty patients over 40 years of age with atrial septal defects were operated on between 1981 and 1989. They were divided into two groups according to operative technique, group A of patients with direct suture of defect (17 cases) and group B patch closure (13 cases), in order to investigate the incidence of postoperative complications. Patient age and size of defect in group B were both greater than in group A. One group A patient had pulmonary stenosis, two group B patients had mitral valvular disease and six group B patients had pulmonary hypertension. The incidence of postoperative heart failure was 29% in group A and 61% in group B and that of arrhythmia was 47% and 69% respectively, however there were no intraoperative and postoperative deaths. We concluded that, although a high incidence of postoperative complications was observed in group B, patch closure was recommended for older patients with atrial septal defect because direct suture was more likely to distort the atrial septum.

[Surgical treatment of ventricular septal rupture following myocardial infarction in an aged patient with bronchial asthma].

Urgent surgery for ventricular septal rupture following myocardial infarction in a 75-year-old female with bronchial asthma was successfully performed. On Feb 28, 1988, she had chest pain, and was admitted 5 days later because of the appearance of heart murmur. Pansytolic murmur (Levine 4/VI) on 3 LSB and piping sound on both lung fields was heard, ECG showed acute anteroseptal infarction. Right heart Swan-Ganz catheterization revealed left to right shunt, and the diagnosis was ventricular septal rupture following acute anteroseptal infarction with bronchial asthma. The initial hemodynamic condition was not serious, but soon after the diagnosis was confirmed, IABP was inserted and operation was indicated because of the advanced age, high shunt ratio (70%) and complication of bronchial asthma. The operation was performed a day after septal rupture. The perforation in the ventricular septum of the apex was sutured with a xenopericardium patch by mattres sutures through a left ventricle approach, and the ventricular wall was closed with this patch together. The postoperative course was uneventful, and the patient was discharged on the 43rd day after the operation.