Case report of a papillary fibroelastoma arising from the left ventricular outflow septum just beneath the aortic valve.

Cardiac papillary fibroelastomas are rare benign tumors with frond-like growths that typically involve the native valve tissue. Papillary fibroelastomas originate less commonly in the ventricular septum. We report a rare case of fibroelastoma arising from the left ventricle.

[Anesthetic management of awake coronary artery bypass grafting using dexmedetomidine--high-dose administration and pharmacokinetic simulation].

We experienced anesthetic management using dexmedetomidine for awake coronary artery bypass grafting (ACAB) in a patient with cerebrovascular and lung diseases. Epidural anesthesia was performed using only local anesthetics, and narcotics were not administered for epidural anesthesia or general anesthesia. The patient complained of discomfort when the surgical maneuver reached the superior extremity of the sternum and when pneumothorax occurred. Pain during the surgical maneuver was relieved by bolus infusion of dexmedetomide 0.1 microg x kg(-1) in addition to injection of a local anesthetic and infusion of a local anesthetic by an epidural catheter. SpO2 decreased to 94% until suturing of the pleura, but the patient did not complain of dyspnea when the rate of continuous infusion of dexmedetomidine was increased to 1.4 microg x kg(-1) x h(-1). Hemodynamics was stable in the intraoperative period, although the plasma concentration of dexmedetomidine calculated by pharmacokinetic simulation analysis, exceeded 1.6 ng x ml(-1). Aggravation of cerebrovascular or lung disease did not occur in the perioperative period. Dexmedetomidine may be useful for ACAB.

Intraoperative mapping of the right atrial free wall during sinus rhythm: variety of activation patterns and incidence of postoperative atrial fibrillation.

OBJECTIVE: The atrial conduction properties associated with cardiac disease are speculated as the background of postoperative atrial fibrillation (POAF). We examined the atrial conduction patterns and conduction properties during sinus rhythm (SR) in patients that had undergone cardiac operations and evaluated the incidence of POAF in all patients. METHODS: Fifty-two patients with stable SR who underwent cardiac surgery, with a diagnosis of valvular disease in 25, ischemic heart disease in 24, and others in 3, were enrolled in this study. The epicardial recordings were made using a mapping system with 60 unipolar electrodes placed on the right atrium (RA) intraoperatively. The activation patterns of the RA were assessed, and the longitudinal, transverse and oblique conduction velocity and max anisotropic ratio were also examined. RESULTS: Sinus activation was initiated from various sites (single origin at the high-lateral RA in 40, mid-lateral RA in 4, low-lateral RA in 2, and multiple origins in 6 patients) and it demonstrated anisotropic conduction (1.8+/-0.6) with the longitudinal conduction being more rapid than transverse and oblique conduction. Fifteen patients demonstrated non-uniform activation patterns such as, a localized conduction delay in seven, functional conduction block in two and mosaic-activation pattern associated with multiple origins in six. A total of 21 patients (44%) developed POAF. A conduction delay and mosaic activation pattern was found significantly more often in patients with POAF than in patients who remained in sinus rhythm. Multivariate analysis revealed that non-uniform activation pattern (odds ratio=8.71; 95% confidence interval [CI]=1.74-43.67; p=0.008) and TR (odds ratio=4.95; 95% CI=1.14-21.37; p=0.032) were independently associated with the development of POAF. Although all patients had converted to SR at the time of discharge, the administration of antiarrhythmic drugs caused sinus bradycardia in two patients who demonstrated a mosaic activation pattern in RA. CONCLUSIONS: Cardiac surgery patients exhibited a variety of sinus activation patterns, which also provided an arrhythmogenic substrate for POAF. A better understanding of the sinus activation using an intraoperative mapping system may provide benefit in the clinical management of POAF.

Surgical experience of subacute pulmonary thromboembolism with severe pulmonary hypertension.

Surgical treatment for subacute pulmonary arterial thromboembolism has previously been considered to be inappropriate. We undertook a pulmonary arterial thrombectomy and removal of a floating right heart thrombus in a patient who had been symptomatic for over a month. The pulmonary arterial pressure, which had been equal to the systemic pressure preoperatively, decreased gradually and almost normalized one month postoperatively. Pulmonary perfusion scintigraphy revealed a dramatic improvement and the patient returned to normal life activities.

Surgical treatment of free-floating thrombi in the right side of the heart in patients with pulmonary thromboembolism.

Floating right heart thrombi (FRHTs) are rare in patients with acute pulmonary thromboembolism (PTE). FRHTs are an extreme therapeutic emergency, and any delay in treatment could be lethal. Heparin, thrombolysis, and catheter therapy are used most frequently to treat acute PTE. Here we present three cases involving operative treatment of FRHTs associated with PTE. Diagnose were made with echocardiography before proceeding to emergency surgery. Thromboembolectomy was performed on cardiopulmonary bypass. One patient became brain dead 10 days postoperatively owing to cardiopulmonary arrest before surgery. The two survivors were subsequently discharged home after uneventful recoveries.

Single-vessel revascularization with minimally invasive direct coronary artery bypass: minithoracotomy or ministernotomy?

STUDY OBJECTIVES: To compare the early outcome in patients who underwent off-pump single-vessel revascularization of the left anterior descending coronary artery (LAD) using two different approaches of minimally invasive direct coronary artery bypass grafting (MIDCAB): left anterior small thoracotomy (LAST) and lower ministernotomy. DESIGN: A retrospective analysis of the medical records on length of the skin incision, total operation time, duration of mechanical ventilation, blood transfusion rate, ICU stay, postoperative wound pain, and morbidities. PATIENTS: Thirty-two patients who underwent MIDCAB with the left internal thoracic artery to the LAD for single-vessel disease were studied. LAST was performed in 16 patients, and ministernotomy was performed in 16 patients. For the ministernotomy approach, the lower half of the sternum was split without transverse division, which we called the lower-end sternal splitting (LESS) approach. Postoperative pain was evaluated using a face-rating scale (scale, 1 to 6). RESULTS: There were no significant differences between the two groups in length of the skin incision, duration of mechanical ventilation, and ICU stay. Total operation time was shorter in the LESS group than in the LAST group (p < 0.05). No patients received a blood transfusion in either group. Atrial fibrillation developed in one patient in the LAST group and two patients in the LESS group. Early graft potency was 94% in the LAST group and 100% in the LESS group (p = 0.48). In the LAST group, subcutaneous emphysema developed in three patients and superficial wound dehiscence developed in two patients, but these complications were not observed in the LESS group (p < 0.05). Postoperative pain was significantly higher in the LAST group up to postoperative day 7 (p < 0.05). CONCLUSIONS: Although LAST is the most commonly used approach for MIDCAB, wound complications and postoperative pain with this technique are not insignificant compared with the lower ministernotomy approach.

Paraganglioma of the posterior mediastinum diagnosed by immunohistochemical staining.

Paraganglioma of the mediastinum are rare neoplasms. To date, no definitive morphologic criteria exist that correlate with the clinical outcome of these tumors. We have encountered a case of paraganglioma in which biological behavior was assessed by immunohistochemical staining to determine whether supplementary postoperative treatment was needed. A 28-year-old man came to our hospital because of an abnormal shadow on a radiogram of the chest. He had no symptoms. Hematological findings were unremarkable. Diagnostic imaging suggested a neurogenic tumor. Surgical resection was performed in September, 2002. A typical nesting pattern (Zellballen) and positivity for chromogranin on immunohistochemical staining were evident, indicating neuroendocrine characteristics, and paraganglioma was diagnosed. Tissue specimens indicated an MIB-1-labeling index of 1.3% on MIB-1 staining, and a relatively well maintained distribution of S-100 protein-positive sustentacular cells, which were suggestive of a benign tumor. The patient did not receive any supplementary therapy postoperatively but was given careful follow-ups.