Coexistence Case of Papillary Fibroelastoma and Lambl's Excrescence of the Left Heart, Which Is Occasionally Associated with Significant Stroke.

Papillary fibroelastoma (PFE) is a benign tumor that arises mostly from left-sided valves. PFE can cause stroke, and surgical resection may be needed. Lambl's excrescence (LE) is a filiform valvular lesion and is considered a possible cause of stroke. A 79-year-old man with light-headedness and left-sided hemiparesis was diagnosed with stroke. Transesophageal echocardiography (TEE) revealed a round-shaped mobile mass in the left ventricular outflow tract (LVOT), which was considered the cause of the stroke. Surgical resection was performed transaortically, and during surgery, a mass was incidentally detected on the noncoronary cusp (NCC), which was also resected followed by aortic valve replacement. Pathology confirmed that the mass in the LVOT was a PFE and that the filiform mass on the NCC was LE. We herein report a rare case of PFE in the LVOT and coexisting LE on the NCC. A careful examination via TEE helps to identify other possible causes of stroke hidden behind the obvious cause.

[Right Brachial Artery Thromboembolism After Left Upper Lobectomy].

A 71-year-old man underwent a computed tomography( CT) scan to check for prostate cancer metastasis. It revealed a lung tumor in the left upper lobe, and he was referred to our division. Under clinical diagnosis of primary lung cancer, left upper lobectomy was performed. Dense adhesion due to the history of tuberculosis was observed. On the first postoperative day, he complained of sudden numbness in his right arm during rehabilitation. The emergent contrast-enhanced CT revealed the right brachial arterial thromboembolism. We performed an embolectomy, and further analysis of the postoperative enhanced CT revealed a longer left upper pulmonary vein stump than usual. We thought it to be the cause of the thrombus formation and started anticoagulation therapy. The postoperative course was uneventful, without recurrence of thromboembolism.

Management of fulminating non-cardiogenic pulmonary edema following cardiac surgery.

A malignant form of non-cardiogenic pulmonary edema (NCPE) that develops soon after the termination of cardiopulmonary bypass support during cardiac surgery is rarely encountered. It sometimes requires immediate management, including venovenous extracorporeal membrane oxygenation (VV-ECMO). In the first case, a 78-year-old female patient experienced fulminating NCPE after mitral valve plasty, which caused severe respiratory failure and hemodynamic instability due to a huge amount of sputum. In the second case, a 47-year-old male patient presented with right-sided unilateral pulmonary edema with a substantial amount of sputum after minimally invasive cardiac surgery for mitral valve repair. In both cases, VV-ECMO and aggressive fluid replacement were promptly initiated. The NCPE resolved on post-operative day 2, resulting in the successful termination of VV-ECMO. NCPE leads to lethal respiratory failure with multifactorial causes during cardiac surgery. However, as NCPE is potentially transient, immediate treatment comprising VV-ECMO and aggressive fluid replacement can improve clinical outcomes.

[Successful treatment of ruptured descending thoracic aortic aneurysm associated with right tension hemothorax during operation].

A 59-year-old man was admitted to the hospital, suspected of the rupture of descending thoracic aortic aneurysm due to sudden back pain. Enhanced computed tomography revealed a ruptured descending thoracic aortic aneurysm with huge hematoma and abdominal aortic aneurysm. Based on the above diagnosis, we performed urgent operation through left thoracotomy under unilateral lung ventilation. While dissecting the aneurysm, sudden hemodynamics deterioration occurred. Although cardiopulmonary bypass was introduced immediately through femoral artery and femoral vein cannulations, hemodynamics was not improved and unilateral lung ventilation got more unmanageable. We diagnosed right tension hemothorax due to the extension of aneurysm rupture into the right thoracic cavity. After placing a cannula at the distal arch for a central perfusion, we clamped the descending thoracic aorta at both the proximal and distal sites of the aneurysm. Thereafter we opened the aneurysm and drained the right thorax through the aneursym's tear. The aneurysm was replaced with a prosthetic woven-Dacron vascular graft. The patient's postoperative condition had been stable with no significant unfavorable event. The abdominal aortic aneurysm was replaced with a bifurcated graft on 51st postoperative day. He was discharged in good condition on the 69th postoperative day.

Vacuum-assisted closure for postcardiac surgery mediastinitis in a patient on hemodialysis.

A 66-year-old man on hemodialysis underwent off-pump coronary artery bypass grafting. He was discharged in good condition on postoperative day (POD) 16. A high-grade fever and a purulent discharge emerged on POD 30. Methicillin-resistant Staphylococcus aureus was identified by culturing material from the wound. On admission, vacuum-assisted closure (VAC) therapy was applied for 80 days. Finally, good wound healing allowed us to perform simple wound closure without using muscle flaps or omentoplasty. VAC therapy is a useful and safe procedure for postcardiac surgery mediastinitis.