Perforation of the esophagus by a fish bone leading to an infected pseudoaneurysm of the thoracic aorta.

A 79-year-old woman was urgently referred to a district hospital with dull central chest pain after swallowing a fish bone. The bone was removed by esophagoscopy. Eleven days later she presented because of hematemesis. Computed tomography and aortic arch angiography confirmed a diagnosis of esophageal perforation leading to mediastinitis and the presence of an infected pseudoaneurysm. The infected pseudoaneurysm was completely resected, followed by direct aorto-aorta anastomosis and omental coverage in a one-stage operation. She improved and was discharged 2 months later.

Early and mid-term results after thoracic aortic surgery in patients aged over 70: survival and effect of the age factor.

OBJECTIVES: The increase in the life span of the Japanese population over the past decade has resulted in a significant increase in elderly patients in cardiac and aortic surgery. This study describes the early and mid-term survival after thoracic aortic surgery, and the influence of age on the operative mortality. METHODS: A total of 85 consecutive patients aged over 70 years underwent a thoracic aortic operation at our institution from January 1995 to June 2005. Their mean age was 76.2 +/- 4.6 years. Their preoperative risk scores were classified into 5 groups (good, fair, poor, high, extremely high) based on the Parsonnet method. RESULTS: There were 10 operative and hospital deaths (11.8%). The survival rates for all patients were 77.8%, 69.4%, and 58.2% at 1, 3, and 5 years, respectively. The major complication was respiratory failure. According to the Parsonnet model, the observed mortality was lower than the predicted mortality. When the age score was excluded in the Parsonnet model, the observed mortality became almost equal to the predicted mortality except in the high-risk group. CONCLUSION: Patients aged over 70 years will undergo thoracic aortic surgery with a reasonable chance of recovery unless there are major preoperative complications. We should consider whether elective surgery can be performed on elderly patients before a rupture develops.

Predictors of surgical indications for acute type B aortic dissection based on enlargement of aortic diameter during the chronic phase.

OBJECTIVES: Patients with Stanford type B dissection who have been treated successfully with medical hypotensive therapy during the acute phase (< 14 days) have the risk of surgery during the chronic phase because of enlargement of the dissected aorta. The objective of this retrospective analysis is to determine the predictors of surgical indications for acute type B aortic dissection by studying chronic-phase enlargements of aortic dissection in patients treated successfully with medical hypotensive therapy. METHODS: Altogether, 131 patients with type B aortic dissection were treated medically during the acute phase between 1987 and 2004. Multivariate factor analyses were performed to determine the predictors of chronic-phase enlargement (> or = 55 mm, as defined for our surgical criteria) of the dissected aorta. RESULTS: Overall dissection-related mortality was 17.6%. Patency of the false lumen was an independent risk factor for dissection-related death (P = 0.0238, hazard ratio 2.594, confidence interval 1.009-6.122) and for dissection-related events (P = 0.0157, hazard ratio 1.870, confidence interval 1.116-3.133). The incidence of patients treated surgically during the chronic phase was 32.8%. The predictors for aortic enlargement during the chronic phase were the condition of maximum aortic diameter > or = 45 mm with a patent false lumen during the acute phase. The rates of freedom from aortic enlargement (> or = 55 mm) for patients with maximum diameter (> or = 45 mm) with a patent false lumen during the acute phase at 1, 5, and 10 years were 72.6%, 66.0%, and 42.8%, respectively, whereas in patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen the values were 100%, 94.7%, and 89.2%, respectively (P < 0.005). CONCLUSIONS: These data suggest that patients with acute type B dissection with a patent false lumen or a diameter > or = 45 mm (or both) during the acute phase are at risk for enlargement of the dissecting aorta. The patients with dissecting aortas > or = 45 mm or a patent false lumen (or both) therefore require close follow-up to detect enlargement of the dissecting aorta, whereas patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen can stay on conservative therapy.

Carrier-mediated norepinephrine release and reperfusion arrhythmias induced by protracted ischemia in isolated perfused guinea pig hearts: effect of presynaptic modulation by alpha(2)-adrenoceptor in mild hypothermic ischemia.

Yohimbine, an alpha(2)-adrenoceptor antagonist, has been reported to protect hypoxic myocardium and inhibit carrier-mediated norepinephrine (NE) release and reperfusion arrhythmias (ventricular fibrillation; VF) in normothermic ischemia. In heart surgery, mild hypothermic (tepid) cardioplegia has been reported to reduce metabolic demand and permit immediate recovery of cardiac function. Therefore, we determined the effect of yohimbine on NE release and reperfusion arrhythmias in isolated perfused guinea pig hearts of tepid temperature (32 degrees C) ischemia model. Stepwise increase of global ischemia period (20, 40, and 60 min) induced a progressive increase of NE release and duration of VF. Neuronal uptake 1 inhibitor desipramine (100 nM) and Na(+)-H(+) exchanger inhibitor 5-N-ethyl-N-isopropyl-amiloride (10 microM) decreased NE and VF in 60-min hypothermic ischemia. This indicated that NE release induced by protracted tepid ischemia was due to carrier-mediated release. Yohimbine (1 microM) markedly reduced NE release and VF (p < 0.01 versus control) and 5-bromo-N-(4,5-dihydro-1H-imidazol-2-yl)-6-quinoxalinamine [UK 14,304 (UK); 10 microM], an alpha(2)-adrenoceptor agonist, increased NE release and VF (p < 0.01 versus control). Yohimbine (1 microM) prevented the potentiated effect of UK (10 microM) in hypothermia (p < 0.01 versus UK). Our findings indicate that presynaptic reduction of carrier-mediated NE release seems to be one of the most important factors controlling reperfusion arrhythmias, and alpha(2)-adrenoceptor blockade by yohimbine (1 microM) in tepid ischemia may contribute to effective myocardial protection in terms of NE release and reperfusion arrhythmia.

Dissecting aneurysm of the infrarenal abdominal aorta: report of a case.

A primary abdominal aortic dissection is exceedingly rare, especially in the absence of blunt abdominal trauma. We herein report a case of aortic dissection with aneurysmal dilatation (dissecting aneurysm) of the infrarenal abdominal aorta in a 61-year-old female patient, and discuss the diagnostic and therapeutic management of this rare disorder.