Resection of Myxoma in the Acute Phase of Hemorrhagic Cerebral Infarction / 日本心臓血管外科学会雑誌

Early surgical resection for cardiac myxoma is necessary because it may frequently cause cerebral infarction. However the optimal surgical timing for the disease is controversial because the acute phase of infarction may induce intracranial hemorrhage. An 82-year-old woman referred to our hospital because of unconsciousness and right hemiparesis. MRI showed infarction in the left middle cerebral artery area and UCG revealed a left atrial mass. The fourth day after the onset, brain CT showed hemorrhagic infarction and MRI showed new infarction. There was no enlargement of the hemorrhagic focus on brain CT and the patient underwent surgery on the fifth day after the onset. The postoperative course was uneventful. Despite the existence of hemorrhagic infarction, open heart surgery may save patients with cerebrovascular event.

A Case of Constrictive Pericarditis after Open-Heart Surgery Effectively Treated with Pericardiectomy / 日本心臓血管外科学会雑誌

Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5 <i>l</i>/min/m² to 2.7 <i>l</i>/min/m², and central venous pressure improved from 17 to 10 mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.

A Case of Acute Myocardial Infarction after Thrombolytic Therapy for Mechanical Valve Dysfunction in the Late Postoperative Phase / 日本心臓血管外科学会雑誌

The patient was a 65-year-old man who had undergone AVR (SJM Regent : 19 mm) for AR in June 2007. Since March 2008 there had been an increase in the pressure gradient between the aorta and the left ventricle on transthoracic echocardiography (peak PG : 46 mmHg, mean PG : 27 mm Hg). Plain x-ray films of the valve showed limited opening of the metallic valve. However, no symptoms of heart failure were observed on a physical examination. Blood tests performed in December 2007 showed a PT-INR value of 1.22. Since the effects of warfarin anticoagulant therapy were insufficient, its dose was adjusted on follow-up. An examination in June revealed further stenosis of the valve (peak PG : 93 mmHg, mean PG : 58 mmHg). Valve thrombosis was suspected because the condition was poorly controlled by warfarin. Thus, thrombolytic therapy using t-PA was performed (800,000 units). However, the patient complained of chest pain 1 h 30 min after initiation of thrombolytic therapy. Twelve-lead electrocardiography was performed, and ST-segment elevations were observed in the limb and chest leads. Acute myocardial infarction due to a free-floating thrombus was suspected, and emergency cardiac catheterization was performed. Segment 7 was totally occluded, and reperfusion was achieved by thrombus aspiration. Embolization of the coronary artery was speculated to have occurred because of the improved mobility of the metallic valve and dissolution of a thrombus adhering to the valve. A case of acute myocardial infarction as a complication of thrombolytic therapy for valve thrombosis is rare. This case reaffirms the necessity of careful monitoring during thrombolytic therapy.