[Commando Procedure for Rapidly Progressing Infective Endocarditis in Immunosuppressive State: Report of a Case].

A 68-year-old woman with immunosuppressive state following chemotherapy for cancer of unknown primary origin developed infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA). Echocardiography showed shunt blood flow from the aortic annular abscess into the left atrium, which indicated infection of the intervalvular fibrosa (IVF). She underwent Commando procedure owing to progression of heart failure. The aortic valve, IVF, and anterior leaflet of the mitral valve were resected. The mitral valve was replaced with a bioprosthesis, and a bovine pericardial patch was used to reconstruct the IVF and left atrial roof. Bentall procedure was performed because the infection extended to the sinus of Valsalva, and the ascending aorta was 49 mm in diameter. She had no serious postoperative complications and is currently being followed up at the outpatient clinic. Because infection in these patients are potentially fatal, we believe Commando procedure is effective in spite of high early mortality rate.

Early and Late Surgical Outcomes after Geometrical Infarct Exclusion for Post-Infarct Ventricular Septal Perforation.

PURPOSE: Ventricular septal perforation (VSP) is a critical complication of acute myocardial infarction. Various surgical procedures for it have been developed; however, surgical outcomes remain unsatisfactory. In 2010, we introduced geometrical infarct exclusion (GIE) as a modification of the Komeda-David technique. This retrospective study compared the surgical outcomes of our geometric infarct exclusion technique to those of other surgical procedures. METHODS: This study included 38 patients who underwent surgery for VSP. They were divided into patients who underwent GIE (GIE group; n = 17) and those who underwent other procedures (non-GIE group; n = 21). The clinical outcomes of the two groups were compared. RESULTS: Operation, cardiopulmonary bypass, and cardiac arrest times in the GIE group were significantly longer than those in the non-GIE group (p <0.001). A residual shunt was observed in one patient (5.8%) in the GIE group and eight (38.0%) in the non-GIE group (p = 0.026). No patients in the GIE group required a reoperation for the residual shut, while two patients required it in the non-GIE group (p = 0.492). Operative mortality was insignificantly different between the two groups. CONCLUSION: Geometric infarct exclusion has a longer procedural time than does other surgical procedures but can reduce the rates of residual shunts and reoperations.

Huge Primary Cardiac Malignant Lymphoma in the Left Ventricle.

A 67-year-old man presented at the hospital with worsening exertional dyspnea. Echocardiography showed a tumor in the left ventricle (approximately 35 × 48 mm) that protruded into the left atrium and left ventricular outflow tract during systole. These findings suggested a high risk of sudden death resulting from aortic valve obstruction or tumor embolism. Surgical resection was performed. During the operation, the tumor was resected as completely as possible, together with part of the myocardium where it arose. Histopathologic examination showed diffuse large B-cell lymphoma. The patient received systemic chemotherapy and is alive after 1 year.

Combined therapy using interventional radiology and surgical management for a ruptured pseudoaneurysm of the iliac artery: A case report.

INTRODUCTION: An optimal treatment strategy for a ruptured pseudoaneurysm of the iliac artery must necessarily control bleeding and prevent ischemia in the ipsilateral lower extremity. PRESENTATION OF CASE: A 69-year-old man underwent resection of a metastatic lymph node from rectal cancer, which had invaded the sigmoid colon, the left internal iliac artery and vein, and his left ureter. The metastatic lymph node and the organs it invaded were resected together. Owing to postoperative complications, the patient was required to undergo a 2nd and 3rd operation after the initial surgery. During his 3rd surgery, sudden intraoperative bleeding was identified, which was diagnosed as a ruptured pseudoaneurysm of the internal iliac artery. After achieving temporary surgical hemostasis, the lesion was successfully treated using combined therapy comprising catheter embolization and an axillofemoral bypass. DISCUSSION: Even after temporary surgical hemostasis has been achieved, it is perhaps safer to block the arterial flow prophylactically to avoid recurrence of a pseudoaneurysm owing to infection. CONCLUSION: Combined therapy using catheter embolization and surgical revascularization is a minimally invasive and effective treatment option for a ruptured pseudoaneurysm of the iliac artery.

Pseudoaneurysm rupture after acute Type A dissection repair: possible reaction to BioGlue.

A 45-year-old man with acute Type A aortic dissection underwent the ascending aorta replacement with BioGlue (CryoLife Europa, Guildford, Surrey, UK) for anastomotic reinforcement. Postoperatively, he developed descending aortic dilation, a giant mediastinal cyst, Henoch-Schonlein purpura and an anastomotic-site pseudoaneurysm rupture. A BioGlue-induced inflammatory reaction was likely, according to a positive patch test (delayed allergic reaction).

[Surgical Treatment of Right Atrial Malignant Tumor Thrombus Under Deep Hypothermia with Intermittent Circulatory Arrest;Report of Two Cases].

Right atrial tumor thrombus is rare in patients with visceral malignant tumors and can cause right heart failure or sudden death. We present 2 cases of right atrial tumor thrombus treated under deep hypothermic intermittent circulatory arrest (DHICA). A 45-year-old man with right heart failure was diagnosed with right renal cancer extending to the right atrium. Computed tomography revealed no metastasis. He underwent right nephrectomy and tumor thrombus resection under DHICA. He was discharged on postoperative day 11 in good clinical course. A 67-year-old woman with hepatitis C virus liver cirrhosis( Child-Pugh A) was diagnosed with hepatocellular carcinoma and right atrial tumor. She underwent S8 and tumor thrombus resection under DHICA. Hemorrhagic diathesis was controlled using fresh frozen plasma transfusion. She was discharged on postoperative day 24 without liver failure. In cases of atrial tumor thrombus resection, DIHCA may be useful to achieve a bloodless operation field because the procedure is relatively simple and the primary disease need not be considered.

[Effect of Ultra-fast-track Extubation in Cardiovascular Surgery].

Fast-track surgery has been widely implemented and allows such immediate extubation as in the operating room(OR). We retrospectively investigated the effect of routine ultra-fast-track(UFT) surgery extubating in the OR in patients undergoing cardiovascular operations. Among 333 consecutive patients, 224 (67.3%)were extubated in the OR. Five patients were re-intubated, but none were because of heart or respiratory failure. Independent predictors for failure of OR extubation were preoperative renal failure, pre-existent cerebrovascular disease, emergency surgery, and prolonged operation and/or cardiopulmonary bypass times. In patients extubated in the OR, postoperative pneumonia and delirium were less frequent, oral intake was facilitated, and lengths of stay in the intensive care unit as well as hospital were shortened. UFT in cardiovascular surgery can be safely and effectively performed in a majority of patients.

[Leaflet Augmentation with an Autologous Pericardial Patch for Severe Functional Tricuspid Regurgitation].

An 85-year-old man, who had developed right-sided heart failure associated with isolated severe tricuspid regurgitation (TR), was referred to our institution to undergo cardiac surgery. Preoperative echocardiography revealed tricuspid annular dilatation and leaflet tethering, resulting in severe TR. The anterior leaflet was detached from the annulus with 1.5 mm margin for suture incorporation, and an autologous pericardial patch was sutured with 3 5-0 running interlocked sutures to augment the leaflet. Annuloplasty was then performed with an undersized ring. Postoperative echocardiography showed trivial TR with good coaptation of the tricuspid leaflets. This technique may be a therapeutic option for the surgical treatment of severe functional TR due to lack of leaflet coaptation.

[Stuck valve detected during aortic valve replacement; report of a case].

Aortic valve replacement, ascending aorta replacement and coronary artery bypass grafting were performed in a 61-year-old woman with aortic stenosis, ascending aortic aneurysm, and angina pectoris. However, immediately after surgery, transient hypotension and pulmonary hypertension repeated every few beats.Transesophageal echocardiography revealed a stuck valve, and reimplantation was carried out. The patient's postoperative course was uneventful. We present a case of successful treatment of valve dysfunction immediately after valve replacement.

Surgical procedure for coronary artery ectasia associated with saccular fistula.

Echocardiography of a 60 year-old woman with a three-year history of heart murmur revealed a coronary artery fistula. Coronary angiography indicated right coronary artery ectasia and fistula. The pulmonary-to-systemic blood flow ratio was 1.4, and left-to-right shunt, 29%. On follow-up, infective endocarditis of the tricuspid valve had developed and was treated using antibiotics. The right coronary artery was dilated along its length and was saccular at the distal aspect. At this point, a fistula also connected by the left anterior descending and left circumflex arteries drained into the right ventricle. Fistula closure and reduction aneurysmectomy were performed.

Mitral valve repair in patient with absent right superior vena cava in visceroatrial situs solitus.

We report on a 74-year-old woman with an absence of right superior vena cava in visceroatrial situs solitus who underwent mitral valve plasty for severe mitral regurgitation. Preoperative three-dimensional computed tomography revealed an absent right and persistent left superior vena cava that drained into the right atrium by way of the coronary sinus. Perioperaively, placement of pulmonary artery catheter, site of venous cannulation, and management of associated rhythm abnormalities were great concern. Obtaining the information about this central venous malformation preoperatively, we performed mitral valve plasty without any difficulties related to this anomaly.

[Surgical case of severe coronary artery obstructive disease with a giant coronary aneurysm; report of a case].

Coronary aneurysms in adults are rare. The natural history of such coronary aneurysms is unknown. Surgical treatment is often concomitant with the treatment of obstructive coronary lesions. However, the ideal treatment strategy is poorly defined. We herein present a case of successful treatment of a large coronary artery aneurysm with interposition of a reverse saphenous vein graft. This modality offers important benefits over other currently used surgical and percutaneous techniques, and should be considered as an effective option.

Staged surgical repair for extensive cardiovascular damage by syphilis.

A 45-year-old man had aortic regurgitation with a syphilitic true aneurysm of the ascending to transverse arch aorta and a descending aortic aneurysm from chronic Stanford type B aortic dissection. After antibiotic therapy, two-staged surgical repair was performed and there has been no evidence of recurrence in 12 months since the second stage. We describe the successful management of extensive cardiovascular syphilitic damage.

Pulmonary and deep vein thrombosis in a young patient with protein S deficiency: report of a case.

A 27-year-old man, who was diagnosed as having familial protein S deficiency, developed deep vein thrombosis complicated with pulmonary thromboembolism. Anticoagulant therapy and thrombolytic therapy were commenced after the insertion of a temporary inferior vena cava filter (t-IVC-f). However, on day 5 after t-IVC-f insertion, IVC venography showed filter thrombosis. On day 13, we made a venotomy and removed the captured thrombi and inserted a permanent IVC-f. After removal of the t-IVC-f via the right brachial vein, thrombi that had not been seen earlier appeared in the right atrium (RA). It was suspected that the thrombi around the catheter had likely been stripped off during the catheter removal procedure. After the abdomen was closed, an extra operation was immediately performed. Under complete extracorporeal circulation, the RA was opened and the all thrombi were removed. The patient recovered well and was discharged on the 21st postoperative day without any complications.

A case of incarcerated femoral hernia in an infant.

The authors describe the case of an incarcerated femoral hernia in an infant. A 4-month-old female infant was hospitalized with an incarcerated right groin hernia. Attempts to reduce the mass were unsuccessful, so an emergency surgery was performed. During surgery, the hernial sac seemed to protrude under the inguinal ligament. The authors opened the hernial sac and observed a dark red small intestine. The authors did not resect the intestine because its color gradually improved after the constriction was released. The hernial sac passed under the inguinal ligament, and the infant was diagnosed with incarcerated femoral hernia.

Nonocclusive mesenteric ischemia after aorto-iliac reconstruction of a ruptured abdominal aortic aneurysm: report of a case.

We report a case of nonocclusive mesenteric ischemia (NOMI), which developed after Y-grafting for a ruptured abdominal aortic aneurysm (AAA). A 71-year-old man was referred to our hospital with severe abdominal pain and signs of shock. Computed tomography revealed a ruptured AAA, and emergency aneurysmectomy and aortic grafting were performed. However, on postoperative day 7, a large amount of pus was seen oozing from the surgical wound. An emergency laparotomy revealed segmental, highly diffuse necrotic changes of the small intestine, but pulsation of the marginal artery in the necrotic region was palpable and blood flow was well audible by Doppler ultrasound. These findings were consistent with a diagnosis of NOMI.

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older.

OBJECTIVES: Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older. METHODS: To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65-74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early. RESULTS: The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8 +/- 0.5 versus 0.3 +/- 0.5; p < 0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p = 0.0009), delirium in 36.7% versus 11.4%, (p = 0.0004), pneumonia in 6.1% versus 0%, (p = 0.0439), and intubation duration of 88.3 +/- 212.5 hours versus 37.2 +/- 92 hours (p = 0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p = 0.1867). CONCLUSION: These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.

Granulocyte elastase release and pulmonary hemodynamics in patients with mitral valvular disease.

In patients with atrial septal defect in whom pulmonary hypertension could develop as a consequence of left-to-right shunt, the extent of neutrophil-mediated lung injury induced by cardiopulmonary bypass (CPB) is related to the degree of increase in the preoperative pulmonary artery pressure. In the present study, we investigated the relationship between levels of granulocyte elastase (GEL) after CPB and preoperative pulmonary hemodynamics or changes in pulmonary function after the operation in patients with mitral valve disease, in whom pulmonary hypertension could develop as a result of pulmonary venous congestion. The plasma levels of GEL were measured before and after CPB in patients who underwent mitral valve replacement. Respiratory index (RI) was evaluated preoperatively and postoperatively. Preoperative pulmonary hemodynamics were determined within one month of the operation. Granulocyte elastase level rose significantly after CPB from baseline (134.3 +/- 44.6 mg/L versus 2042.1 +/- 1215.0 mg/L; p <0.001). Peak level of GEL was significantly correlated with preoperative systolic pulmonary artery pressure (r = 0.71; p = 0.020), mean pulmonary artery pressure (r = 0.64; p = 0.046), pulmonary capillary wedge pressure (r = 0.68; p = 0.032), and pulmonary-to-systemic arterial pressure ratio (r = 0.64; p = 0.045), but not with the hemodynamic variables for pulmonary blood flow or pulmonary resistance. Moreover, the value of (Postoperative RI - Preoperative RI)/Preoperative RI was positively correlated with the peak level of GEL (r = 0.76; p = 0.011). In conclusion, in patients with mitral valvular disease, as in those with atrial septal defect, the increase in GEL level after CPB is proportional to the increase in preoperative pulmonary artery pressure, which may cause the accordant pulmonary vascular damage.