Left atrial myxoma associated with acute myocardial infarction and multiple cerebral infarctions: Report of a case.

We report a case of left atrial myxoma associated with acute myocardial infarction (AMI) in a 63-year-old man. Percutaneous coronary intervention was performed immediately, and we removed white intracoronary particles by using a thrombectomy catheter. The postinterventional course was uneventful; however, on hospital day 5, pathological examination revealed platelet thrombus and myxomatous tissue from the particles aspirated by thrombectomy catheter, and transesophageal echocardiography showed a gelatinous mass in the left atrium. Based on these findings, we diagnosed AMI caused by coronary embolization from a left atrial myxoma, and excision of the myxoma was scheduled. However, preoperative magnetic resonance imaging revealed multiple subacute cerebral infarctions, and the tumor was successfully excised on hospital day 13. Although coronary embolization induced by cardiac myxoma is rare, it should be considered in a young to middle-aged patient presenting with signs of AMI without coronary risk factors.

Report of simultaneous off-pump CABG and modified mastectomy.

The patient was a 75-year-old female who had received medical treatment for effort angina. Recently, she noticed a left breast tumor, which was diagnosed as breast cancer with axillary lymph node swelling. Coronary angiography performed prior to the surgery for the breast cancer showed 90% stenosis in segment 6 of the left anterior descending artery (LAD). Coronary intervention was not possible due to anatomical reasons, so she was admitted for simultaneous surgery for the breast cancer and angina. The chest was opened through a median sternotomy and the full-skeletonized right internal thoracic artery was grafted on the LAD without cardiopulmonary bypass. A transverse elliptical incision was made after the median sternotomy was closed, and the breast tumor and lymph nodes around the subclavian and axillary vessels were completely dissected. Even in the case of multiple vessel coronary disease, simultaneous surgery may be possible, but indications should be carefully assessed considering the cardiac function and general condition of the patient.

Evaluation of coagulant activity after mechanical heart valve replacement.

Long-term oral anticoagulant therapy is required for recipients of mechanical heart valves. In our hospital, the international normalized ratio of prothrombin time (PT-INR) has been set in the range 1.5-2.5 since October 2001. To evaluate whether coagulant activity is fully suppressed by this target range, coagulant activity was evaluated by measuring thrombin-antithrombin III complex (TAT) levels and valve-related complications were investigated retrospectively. Two hundred twenty-three patients who underwent mechanical valve replacement were enrolled in this study. PT-INR and TAT were measured at our outpatient clinic in March 2005 and valve-related complications since October 2001, when we started to control PT-INR in the range 1.5-2.5, were investigated. Under adequate warfarin control, there was no significant correlation between PT-INR and TAT, however nine patients who exhibited a PT-INR of less than 2.0 had high levels of TAT. And in atrial fibrillation (AF) patients after mitral valve replacement (MVR), the level of TAT was significantly high compared with sinus rhythm patients after atrial valve replacement. Valve-related complications were bleeding events at 2.75% per patient year and thromboembolism at 0.32% per patient year. Attention to complications of thromboembolism is necessary when the PT-INR is less than 2.0, especially in AF patients after MVR and in those with a thrombotic past history or high levels of TAT. The monitoring of TAT is useful in detecting potential coagulation factors and to determine the therapeutic range of warfarin that can normalize coagulant activity.

A surgical case for a Carbomedics stuck valve due to thrombotic pannus formation in the mitral position.

The patient was a 61-year-old female. She underwent mitral valve replacement (MVR) with a 27 mm Carbomedics valve and tricuspid valve annuloplasty using the DeVega method in September 1997. She has received anticoagulant therapy by aspirin and warfarin in a nearby hospital. Because of aggravating dyspnea and chest pain after an acute upper respiratory inflammation, she was transferred to our hospital on an emergency basis on April 14, 2003. Upon admission she went into cardiogenic shock and multiple-organ failure. Biolite carbon coating prevents adhesion of thrombus or pannus on the sewing cuff of Carbomedics valve, and there were few reports of Carbomedics valve dysfunction by pannus formation. But in this case cineradiography demonstrated the prosthetic valve was fixed in the closed position. We diagnosed acute heart failure due to a stuck valve in the mitral position, and redo MVR was performed in emergency. Thrombotic pannus extended from the sewing cuff and into the orifice on the inflow and outflow sides of the valve, and fixed both leaflets in a closed position. The postoperative course was uneventful, and she was discharged on the 20th postoperative day, and now anticoagulant therapy is managed in the outpatient clinic of our hospital. A combination of cineradiography and echocardiography provides a detailed diagnosis of asymptomatic valve dysfunction. Periodical examination by a prosthetic valve specialist is necessary in order to perform adequate anticoagulant therapy, echocardiography and cineradiography after prosthetic valve replacement.

Abdominal aortic aneurysm associated with crossed renal ectopia without fusion: case report and literature review.

Genitourinary anomalies can present a formidable challenge to the vascular surgeon at abdominal aortic reconstruction. We saw a case of crossed renal ectopia without fusion, a rare anomaly, associated with abdominal aortic aneurysm. Because of risk for injury to the kidney during surgery, preoperative evaluation of this anomaly must include computed tomography, angiography, and intravenous pyelography. Preoperative placement of a ureteral catheter may prevent injury to the anomalous ureter. Renal failure of the ectopic kidney during aortic reconstruction can be a serious problem. We used in situ hypothermic perfusion with cold (4 degrees C) Ringer solution for renal protection, and reimplanted the aberrant renal artery. The postoperative course was good, without major complications. The procedure for renal preservation must be selected on the basis of anatomic findings. We review the literature and present the first case of crossed renal ectopia.