[Surgical Removal of Left Atrial Thrombus Originating from the Left Upper Pulmonary Vein Stump after Left Upper Lobectomy;Report of a Case].

Left upper lobectomy may be a risk factor for thrombosis in the pulmonary vein stump. We report a case of surgical removal of a left upper pulmonary vein stump thrombus after left upper lobectomy. A 73-year-old man with transit ischemic attack had a history of left upper lobectomy for pulmonary tuberculosis 40 years before. Echocardiography and chest computed tomography (CT) scan revealed a mobile thrombus in the left atrium originating from the left upper pulmonary vein stump. Surgical removal of the thrombus as well as the left upper pulmonary vein stump was performed under extracorporeal circulation and cardioplegic cardiac arrest. Pathological examination of the pulmonary vein stump revealed no growth of tumor nor injury of endothelial cells. Postoperative course was uneventful and no recurrence of the thrombus was observed during 7 years after surgery.

[Endoscopic saphenous vein harvesting with non-disposable device].

Endoscopic vein harvesting (EVH) for coronary artery bypass grafting has been proved to be effective in reduced wound complications, without compromising long-term mortality or composite of death, myocardial infarction and repeat revascularization. However, only disposable devices that are costly and raise environmental problems, have been obtained on the market in Japan. Now, a non-disposable device for EVH is available. With this equipment, a 50 cm-long great saphenous vein can be obtained with a single 3 cm-long incision. We demonstrate how to use this device and show its tips and pitfall.

[Surgical treatment for acute type A aortic dissection].

The purpose of this study was to assess the factors for clinical outcome of the surgical treatment of acute type A aortic dissection. From April 1996 to March 2006, 44 patients underwent emergency operation for acute type A dissection within 2 weeks from the onset. Resection of the intimal tear was performad with open distal anastomosis. The mean age was 63.4 (range 29-83) years, and 28 were female. As for their preoperative condition, 5 patients were in severe hemodynamic instability including cardiac arrest in 2, apnea in 1, and rupture in 4. Distal resection extended to ascending aorta in 24 patients (54.5%), hemiarch in 7 (15.9%), and total arch in 13 (29.5%). 30-day mortality was 4.5% and the incidence of stroke was 13.6%. Several methods were used including axillary artery cannulation and central repair with adventitial inversion technique. Patients with malperfusions caused by acute type A dissection should undergo immediate aortic reconstruction by adequate circulatory assisting methods.

Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury.

OBJECTIVE: Thoracic aortic aneurysm repair with the stented elephant trunk technique seems to be associated with an increased risk of spinal cord injury. We investigated whether severe atherosclerosis of the distal landing zone or extensive deployment of the stented elephant trunk is associated with increased risk of spinal cord injury. METHODS: Twenty-five patients underwent thoracic aortic aneurysm repair with the stented elephant trunk technique. The study population included 19 men and had a mean age of 73 +/- 7 years. All patients underwent a median sternotomy with cardiopulmonary bypass and selective cerebral perfusion. The elephant trunk was fixed with a Z-stent distal to the aneurysm during hypothermic circulatory arrest. Thirteen patients underwent concomitant total aortic arch replacement. RESULTS: Six (24%) patients had spinal cord injury. The presence of severe atherosclerosis at the distal landing zone demonstrated a tendency to increase the incidence of spinal cord injury (36% vs 9%, P = .1218). More distal deployment of the stented elephant trunk was significantly associated with increased risk of spinal cord injury (T8.0 +/- 0.6 vs T6.5 +/- 1.1, P = .0043). Univariate logistic regression analysis identified a history of abdominal aortic aneurysm repair (P = .0296) and the vertebral level of the distal landing zone (P = .0249) as significant independent risk factors for spinal cord injury, and only the latter was significant in multivariate analysis (P = .0396). The combination of a distal landing zone of T7 or greater and a history of abdominal aortic aneurysm repair was the strongest predictor for spinal cord injury (71% vs 6%, P = .0047). CONCLUSIONS: Spinal cord injury after stented elephant trunk deployment might be related to occlusion of the excessive intercostal arteries or thromboembolism. Patients with a history of abdominal aortic aneurysm repair who require extensive deployment of the stented elephant trunk seem to be at a higher risk for spinal cord injury.

Reoperations after failure of stent grafting for type B aortic dissection: report of two cases.

We describe our successful management of two patients who suffered complications after stent grafting for Type B aortic dissections. One patient was found to have stent-graft migration, which we treated with repeat aortic stent grafting, and the other patient had a proximal endoleak and total occlusion of the stent graft, which we treated with open surgical repair. We discuss the measures used to assist us in deciding on the most appropriate surgery, as well as the treatment alternatives.

Abdominal compartment syndrome causing respiratory failure during surgery for a ruptured descending thoracic aneurysm: report of a case.

Elevated intra-abdominal pressure causing widespread organ dysfunction is known as abdominal compartment syndrome (ACS). The subject of our case report is a 64-year-old man who underwent repair of a ruptured descending thoracic aortic aneurysm (TAA) under deep hypothermic circulatory arrest. During the operation, decompression laparotomy was required to relieve intra-abdominal hypertension causing respiratory failure, before the patient could be weaned off cardiopulmonary bypass. We report this case to alert surgeons to the fact that ACS can occur during surgery on the thoracic aorta, especially if massive fluid resuscitation is required and venous drainage for extracorporeal circulation is less than optimal. Early recognition and prompt decompression by laparotomy is essential to save the life of the patient.

[Overlapping ventriculoplasty for ischemic cardiomyopathy].

We have previously reported overlapping cardiac volume reduction operation (OLCVR) for dilated cardiomyopathy. Because of the acceptable clinical outcome and especially the excellent ellipsoidal shape of the left ventricle (LV) after surgery, we extended this indication for ischemic cardiomyopathy (ICM) with dilated LV. In such cases we combined OLCVR with mitral annuloplasty and papillary muscles approximation (PMA), called integrated overlapping ventriculoplasty (IOLVP). From March 2003 to July 2004, we performed IOLVP with coronary artery bypass grafting (CABG) for 8 patients who were diagnosed ICM. There is no operative mortality. Pre- and postoperative hemodynamics data are follows: LV ejection fraction (LVEF) improved from 22.4 +/- 11.9 to 33.4 +/- 10.5%, LV end-diastolic volume index (LVEDVI) decreased from 155.5 +/- 26.5 to 93.7 +/- 13.5 ml/m2 and LV end-diastolic diameter (LVDd) diminished from 66.0 +/- 8.9 to 60.5 +/- 8.4mm. Mitral regurgitation changed from 2.6 +/- 0.8 to 0.1 +/- 0.2 degree. New York Heart Association (NYHA) functional class improved from 3.3 +/- 0.5 to 1.3 +/- 0.5. LV shape became ellipsoidal without akinesis lesion. IOLVP is considered as a good option for ICM with dilated left ventricle.

Aortoesophageal fistula: alternatives of treatment case report and literature review.

Aortoesophageal fistula (AEF) remains as a life-threatening condition with a high rate of morbidity and mortality. It is usually related to aortic or esophageal disease, and less commonly foreign body ingestion. In spite of several strategies for treatment, there is little consensus regarding the optimal management of this entity. In this paper, we present our experience in successfully managing one patient with AEF by performing open surgical repair. We also include a discussion on criteria for selecting the most appropriate alternative of treatment: open or endovascular repair, based on a review of the literature currently available in MEDLINE.

Bilateral coronary ostial patch angioplasty with autologous pericardium in Takayasu arteritis: a case requiring replacement of the aortic valve and ascending aorta.

Since the lesions and stages of Takayasu arteritis vary with each patient, surgical treatment of this disease requires meticulous planning for the timing of operation, technique, material used, and postoperative medication. We report a rare complex lesion of Takayasu arteritis, which required simultaneous repairs for aortic regurgitation, a dilated ascending aorta and bilateral coronary ostial stenosis. Such multiple lesions have not been reported previously. A 47-year-old woman was referred to us because of heart failure and chest pain. The coronary ostial stenosis were enlarged with generously sized autologous pericardial patches, and separate aortic valve and ascending aortic replacements were performed since the diameter of the Valsalva sinus was 37 mm. The postoperative course was uneventful, but steroid therapy was commenced postoperatively because inflammatory reaction remained high.

Selective perfusion of the upper and lower body under different levels of hypothermia in a patient with coronary artery disease and dissecting thoracoabdominal aortic aneurysm.

Hypothermia is known to protect the myocardium and the spinal cord during ischemia. However the risk of complications increases with lower hypothermic conditions. In this paper we report a 62-year-old male patient with concomitant coronary artery disease who was surgically treated for a thoracoabdominal aortic aneurysm and an abdominal paraanastomotic pseudoaneurysm using selective perfusion of the upper and lower body under mild and deep hypothermia respectively. The patient was discharged uneventfully and only experienced transient delirium. We believe this novel modality may be a promising alternative in selected candidates.