Hyperacute ischemic stroke treated with carotid-carotid artery bypass surgery "case report".

Thrombolytic therapy using heparin, urokinase, and tissue plasminogen activator (tPA) has been the standard treatment for hyperacute ischemic stroke (HIS) with worsening carotid artery stenosis. In recent years, endovascular treatments (thrombectomy and carotid artery stenting) have attracted attention, and neurosurgeons are increasingly participating in these treatments. A 70-year-old Japanese male presented to our hospital with aphasia and right hemiparesis. Emergency computed tomography ([CT] CT angiography and perfusion CT) revealed a small infarct core and a large hemiparesis due to occlusion near the left common carotid artery orifice. Because of hemorrhagic sequelae, tPA was not administered, and emergency endovascular treatment failed. Therefore, a bilateral common carotid artery bypass surgery was performed. Revascularization was performed within 51 min of the start of the surgery, and the time from onset to revascularization was 5 h. Aphasia and right hemiparesis resolved immediately after surgery. The only sequela observed was mild dyskinesia. Our report is the first to show that bilateral common carotid artery bypass is a novel and effective treatment for HIS.

Percutaneous Extraction for Misplacement of Pacemaker Leads Within the Coronary Artery and Left Ventricle.

A 75-year-old man, who underwent inadvertent misplacement of pacemaker leads into the left coronary artery and left ventricle through the subclavian artery, was referred to our hospital. We safely performed percutaneous lead extraction in collaboration with surgeons and with the patient under general anesthesia. (Level of Difficulty: Advanced.).

A case of acute coronary syndrome caused by delayed coronary ischemia after transcatheter aortic valve implantation.

An 84-year-old female patient suffered from dyspnea due to severe aortic stenosis. Several comorbidities and her advanced age made her acceptable for transcatheter aortic valve implantation (TAVI). The TAVI procedure was performed via a femoral access and a 26-mm CoreValve prosthesis (Medtronic, Minneapolis, MN, USA) was implanted. The prosthesis was deployed at a high position because of short distance between the annulus base and coronary arteries. Aortic angiography indicated normal contrast flow into both coronary arteries. Six months later she was readmitted to our hospital because of acute coronary syndrome. Although selective intubation of coronary arteries could not be achieved because of high valve position, both coronary arteries seemed to be well contrasted. As a consequence, the second coronary angiography was undertaken because of recurring chest pains. The aortic root angiogram showed a decreased contrast flow into both coronary arteries. During the examination she deteriorated rapidly, developed cardiopulmonary arrest, and a percutaneous cardiopulmonary support and an intra-aortic balloon pump needed to be inserted. She was then transferred to the operating room for aortic valve replacement. This is the first case of delayed coronary ischemia after TAVI, necessitating the removal of an implanted CoreValve and its replacement with a new prosthetic valve. .

[Clinical Outcomes of Cardiovascular Surgery in Jehovah's Witness Patients].

Cardiovascular surgery in Jehovah's Witness is challenging for surgeons on the ground that they refuse blood transfusion. We report 11 cases of cardiovascular surgery. All of the patients underwent elective surgery with cardiopulmonary bypass. Two cases underwent minimally invasive procedures. The mean preoperative hemoglobin level was 13.0 g/dl, and hematopoietic medicines were preoperatively administrated in 4 patients. Although 10 patients recovered satisfactory without blood transfusion, 1 surgical case was lost due to uncontrollable postoperative bleeding. The clinical outcomes of the Jehovah's Witness patients are considered to be satisfactory. However, careful indication is recommended in high risk cases.

[Extracardiac Aorto-right Atrial Fistula after Aortic Valve Replacement].

The development of a fistula between the aorta and the right atrium is a relatively rare but well-documented complication after cardiac surgery and proximal aortic dissection, and has a high mortality rate if it is not diagnosed adequately and surgically treated without delay. We report a rare case of extracardiac aorta-right atrial fistula. An 86-year-old woman underwent aortic valve replacement via median sternotomy. Two weeks after surgery, the upper median skin incision reopened, which exposed the sternum and revealed purulent discharge inside the wound. Wound and blood cultures were positive for methicillin-resistant Staphylococcus aureus. The wound was treated, and healed in approximately 2 weeks. Six weeks after surgery, the patient suddenly presented with dyspnea because of heart failure.Extracardiac aorto-right atrial fistula was confirmed by computed tomography. During surgery, we found an extracardiac fistula formed in the hematoma between the sites where the aortic vent suture was tied and the caval cannula was removed. The infection seemed to have contributed to the development of the fistula and may have persisted in the ascending aorta or artificial valve, which may have led to cerebral hemorrhage resulting in death 4 months later.

[Pericardiectomy of effusive constrictive pericarditis with an ultrasonic scalpel; report of a case].

Effusive constrictive pericarditis is a rare clinical entity characterized by concurrent pericardial effusion and visceral pericardial constriction. The most effective therapy for this state is pericardiectomy with complete removal of the parietal and visceral membranes, although the perioperative mortality and morbidity can be high. We presented a case of a 45-year-old man in whom a visceral pericardiectomy with waffle procedure was successfully performed using an ultrasonic scalpel without use of cardiopulmonary bypass. His postoperative course was uneventful and cardiac hemodynamics restored to normal. There were no signs or symptoms of recurrence in 2 years of follow-up.

Right lower lobe autotransplantation for locally advanced central lung cancer.

A 44-year-old man with locally advanced central lung cancer was treated by right lower lobe lung autotransplantation after pneumonectomy using an extracellular phosphate-buffered solution for cold lung preservation. The advantage of the ex vivo operation made it possible to perform safe and definitive cancer resection without massive bleeding. Cold lung preservation brought some advantages, such as reducing the risk of ischemia-reperfusion injury compared with warm ischemia and allowing enough time to achieve microscopically negative margins. The patient returned to normal life with minimum loss of pulmonary reserve and no recurrence of lung cancer for 6 months.

A rare cardiac haemangioma in the right ventricle diagnosed accurately using ¹8F-fluorodeoxyglucose-positron emission tomography.

A right ventricular cardiac tumour was incidentally detected in a 61-year-old man during a preoperative examination for coronary artery bypass grafting (CABG). Findings on computed tomography and magnetic resonance imaging suggested the differential diagnoses of myxoma, haemangioma and haemangiosarcoma, and it was difficult to identify whether the tumour was benign or malignant. (18)F-fluorodeoxyglucose-positron emission tomography strongly suggested a benign tumour. We enucleated the tumour, because an intraoperative frozen section also strongly suggested a benign origin. After resection, CABG under cardiopulmonary bypass was performed. Histopathological and immunohistochemical analysis indicated a cavernous haemangioma without evidence of malignant tissue. The patient has survived 20 months after surgery with no evidence of tumour recurrence.

Migration of a retained temporary epicardial pacing wire into an abdominal aortic aneurysm.

A 69-year old male was referred to our hospital for the treatment of coronary artery disease. Preoperative computed tomography (CT) revealed an abdominal aortic aneurysm (AAA) and a giant tumour of the left kidney. He underwent off-pump coronary artery bypass grafting (OPCAB) prior to aneurysmectomy and nephrectomy. Temporary epicardial pacing wires (TEPWs) were placed on the right atrium and right ventricle. The bipolar ventricular wire was removed and the unipolar atrial wire was cut flush with the skin surface on postoperative day 5. CT 7 days after the OPCAB procedure revealed a retained TEPW sutured to the right atrial wall. One month later, the patient underwent a repair of the AAA and left nephrectomy. We found that a TEPW had migrated inside the AAA intraoperatively. The retained TEPW was thus no longer observed on postoperative CT. Migration of the atrial pacing wire through the aortic lumen was suspected, although the detailed mechanism is unknown. This is the first reported case of a migrated temporary pacing wire into the aorta under noninfectious conditions.

Cardiac tamponade due to rupture of coronary artery fistula to the coronary sinus with giant aneurysm of coronary artery: usefulness of transthoracic echocardiography.

A 68-year-old woman was admitted to our hospital because of back pain and syncope. Transthoracic echocardiography revealed pericardial effusion, a collapsed right ventricle, a giant aneurysm connected to the coronary sinus, a dilated left main trunk coronary artery, and a dilated left circumflex artery (LCx). Furthermore, there was a coronary artery fistula arising from the LCx that drained into the coronary sinus. We diagnosed cardiac tamponade due to rupture of the coronary artery fistula or giant aneurysm, and successful emergency surgery was performed. Rupture of coronary artery aneurysm or coronary artery fistula is very rare. Transthoracic two-dimensional echocardiography was very useful in our case for the diagnosis of cardiac tamponade, giant coronary aneurysm, and coronary artery fistula.

Primary leiomyosarcoma of the pulmonary artery: a case of a 20-month survivor after incomplete surgical resection.

We report a 53-year-old man who presented with dyspnea and low-grade fever. Cardiac ultrasound showed pulmonary hypertension and an ill-defined echogenic mass within the pulmonary trunk. Computed tomography scan revealed an inhomogeneous mass which filled the main pulmonary trunk with near-total occlusion, and extended into both pulmonary arteries. Anticoagulant therapy was administered based on a presumptive diagnosis of pulmonary thromboembolism. Positron-emission tomography scan was useful for differentiating the mass, which was determined as a pulmonary artery sarcoma by surgical resection. Although complete resection was impossible, the patient survived for 20 months with adjuvant chemotherapy and medical treatment.

Rapid progression of aortic regurgitation with thoracic aortic aneurysm due to Takayasu arteritis associated with ulcerative colitis.

A 25-year-old woman with ulcerative colitis developed heart failure due to severe aortic regurgitation. Although chest X-ray 18 months previously showed a normal cardiac shadow, thoracic aortic aneurysm progressed due to Takayasu arteritis. Aortic valve and ascending aorta replacement were performed successfully, but re-valve replacement for severe aortic regurgitation due to prosthetic valve detachment and aortic root replacement for valsalva sinus rupture were required. Human leukocyte antigen analysis showed B35 and B52, the typical haplotype in cases with coexistence of both diseases and associated sustained inflammation. Close observation and early aortic root replacement were needed in this case.

Use of continuous retrograde gaseous oxygen persufflation for myocardial protection during open heart surgery.

PURPOSE: The infusion of a cardioplegic solution is the standard method of myocardial protection during open heart surgery. However, this method interrupts the surgical procedure and it is difficult to ensure a bloodless surgical field. To address these problems, the effect of continuous retrograde gaseous oxygen persufflation (ROP) on myocardial protection was assessed in comparison to St. Thomas' solution (STS). METHODS: Eighteen adult mongrel dogs were divided into three groups of six. Group G received continuous ROP, Group C received STS every 30 min, and Group N received hypothermia alone during the 120 min hypothermic ischemia. The myocardial metabolism was assessed by measuring the coronary sinus lactate concentration, lactate extraction ratio (LER), coronary sinus lipid peroxidation (LPO) concentration, left ventricular myocardial adenosine triphosphate (ATP) concentration, and water content. Cardiac function was assessed by the percent recovery relative to the baseline. RESULTS: In Group G, the lactate, LPO, and water content were significantly lower (P = 0.0062, P = 0.03, and P = 0.0065, respectively), and ATP was significantly higher (P = 0.028) than in Group C. The LER was only positive in Group G. In addition, the cardiac functions in Groups G and C were not significantly different. CONCLUSIONS: Retrograde gaseous oxygen persufflation was not inferior to STS in regard to myocardial protection. This technique could therefore represent a potentially promising cardioplegic method.

Successful treatment of spontaneous coronary bypass rupture using a polytetrafluoroethylene-covered stent.

A 57-year-old man with coronary bypass surgery experienced spontaneous rupture of a vein graft 16 months following his operation. Multislice computed tomography revealed a perforation of the saphenous vein graft to the obtuse marginal branch. 3D imaging was useful for diagnosis and in planning treatment. Hesitation to perform surgical treatment occurred due to inflammation in the patient, therefore we successfully implanted a polytetrafluoroethylene-covered stent to occlude the site of perforation. The use of a covered stent for a patient showing clear leakage of dye during angiography should be considered as an alternative to surgical intervention for a ruptured vein.

Taurine-mediated cardioprotection is greater when administered upon reperfusion than prior to ischemia.

UNLABELLED: Taurine (TA) administered exogenously before the induction of myocardial ischemia decreases lactic acid production and increases pyruvic acid production during ischemia. It also preserves the activity of GOT, GPT, LDH and CPK during ischemia and enhances recovery of CKMB synthesis as early as 5 minutes after onset of reperfusion. The aim of the study was to determine the optimal conditions for administering TA in order to reduce myocardial ischemia-reperfusion injury. Left ventricular (LV) function, creatine kinase (CK) and lipid peroxide products (LPOP = oxidant stress), as well as the area at risk (AAR), and infarct size (IS) after reperfusion were studied in 3 groups of isolated rat hearts perfused with Krebs Henseleit Buffer (KHB)-stabilized isolated rat hearts that were subjected to 20 minutes(') of global ischemia at 37 degrees C followed by 60' of reperfusion with KHB: Hearts were perfused with TA containing KHB for 10' just prior to ischemia or during the first 10' of reperfusion. CONCLUSION: Taurine before ischemia or during reperfusion was equally effective in preventing infarction; however, when administered at reperfusion, taurine reduced lipid peroxidation and myocardial injury more, thereby providing improved early recovery of function.

Taurine at early reperfusion significantly reduces myocardial damage and preserves cardiac function in the isolated rat heart.

OBJECTIVE: The Myocardial protective effects of taurine (TA) are well known. We investigated the optimal phase of giving taurine to reduce myocardial ischaemia-reperfusion injury in isolated rat hearts. METHODS: Isolated rat hearts were subjected to 20 min of global ischaemia followed by 60 min of reperfusion under three different conditions: global ischaemia alone (control group; n=8); pre-ischaemic administration of taurine (pre-TA group; n=8), perfusion with 10 mmol/L taurine for 10 min just before ischaemia; post-ischaemic administration of taurine (post-TA group; n=8), perfusion with 10 mmol/L taurine for the first 10 min of reperfusion. Ventricular functional and biochemical variables, the area at risk (AAR), and infarct size (IS) after reperfusion were compared between groups. RESULTS: Recovery of ventricular function in the post-TA group was significantly greater than that in the control and pre-TA groups in terms of left ventricular pressure and rate-pressure product. Lipid peroxide product as a marker of oxidant stress in the post-TA group was significantly less than that in the control and pre-TA groups. AAR relative to left ventricular area in the post-TA group was significantly less than that in the control and pre-TA groups. IS relative to AAR in the post-TA group was significantly less than that in the control group. CONCLUSION: Taurine administered before or after ischaemia prevents infarction; being a potent free radical scavenging antioxidant, it reduced myocardial injury and provided significantly better functional recovery when given immediately after reperfusion.

Effects of ultrasonic skeletonization on internal thoracic and gastroepiploic arteries for coronary artery bypass grafting.

OBJECTIVE: There are few data available on the effect of ultrasonic skeletonization with the harmonic scalpel on internal thoracic artery (ITA) and gastroepiploic artery (GEA) vessel function. METHODS: Rings of segments of the skeletonized ITA, pedicled ITA, skeletonized GEA, and pedicled GEA were studied. Arterial segments were treated with high KCl and norepinephrine (NE) to obtain smooth muscle contractions. Endothelium-dependent and independent vasorelaxant potencies in 10(-6)mol/l NE-pre-constricted arteries were assessed by acetylcholine (ACh), and isosorbide dinitrate (ISDN) and diltiazem, respectively. RESULTS: There were no differences in contractile potencies induced by high KCl and NE between the rings cut from skeletonized and pedicled grafts. The rings from skeletonized and pedicled vessels also showed equal sensitivity to ISDN and diltiazem. However, the rings from pedicled grafts showed greater relaxation responses to ACh than rings from skeletonized grafts. CONCLUSION: Ultrasonic complete skeletonization with the harmonic scalpel may retain smooth muscle function of skeletonized grafts, whereas endothelial function of ultrasonic skeletonized grafts may be significantly compromised.

Mechanism of persistent ischemic mitral regurgitation after annuloplasty: importance of augmented posterior mitral leaflet tethering.

BACKGROUND: We hypothesized that surgical annuloplasty for ischemic mitral regurgitation (MR) that displaces the posterior annulus anteriorly can potentially augment posterior leaflet (PML) tethering, leading to persistent MR. Relationships between leaflet configurations and persistent ischemic MR after the annuloplasty were investigated. METHODS AND RESULTS: In 31 patients with surgical annuloplasty for ischemic MR and 20 controls, posterior and apical displacement of the leaflet coaptation, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, coaptation length (CL), and the MR grade were quantified before and early after surgery in echocardiographic left ventricular long-axis views. Six of the 31 patients showed persistent MR despite annuloplasty. Compared with patients without persistent MR, those with MR showed no improvement in the left ventricular ejection fraction and systolic volume, similar reduction in the annular area, significant increase in posterior displacement of the coaptation (P<0.01), no improvement in AML tethering, greater worsening in PML tethering (P<0.01), and no increase in the CL. All tethering variables were significantly correlated with both preoperative and postoperative MR in univariate analysis, and reduced CL was the primary independent determinant of both preoperative and postoperative MR. Although increased AML tethering was the primary determinant of the preoperative CL (r2=0.46, P<0.0001), increased PML tethering was the primary determinant afterward (r2=0.60, P<0.0001). CONCLUSIONS: Although tethering of both leaflets is the major determinant of ischemic MR before surgical annuloplasty, both leaflets tethering but with predominant and augmented PML tethering is related to persistent ischemic MR after the annnuloplasty.